Forensic Nursing

Forensic Nursing KELLY M. PYR EK

Boca Raton London New York

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2005017336

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Foreword Principles of forensic nursing are being utilized in all aspects of nursing. Originally designed as healthcare’s direct response to violence, this new discipline is now recognized as one of the most basic elements in the scientific and legal approach to the clinical investigation of trauma. By combining the forensic aspects of healthcare with the forensic services afforded to victims and offenders of abuse, neglect, and intentional and nonintentional injury, one can best approach nursing’s holistic care of body, mind, spirit, and now the law, required in a culture of global violence. Elements of daily nursing care are essential to every nurse in every hospital worldwide; however, the laws governing human injury will define the boundaries of forensic nursing practice. The role of the forensic nurse examiner (FNE) and those who will teach, develop, and promote change in antiquated health and justice systems will be recognized as leaders in a contemporary scientific world. The lack of qualified forensic clinicians and forensic pathologists has left a void between critical clinical intervention and the criminal investigation processing of forensic evidence, accurate documentation, and skilled testimony in courts of law. For far too long, these essential services were relegated to physicians alone. With the advent of forensic nursing science, however, a new perspective in the medico-legal case management of victims of crime and those who commit criminal acts was accorded to protect their legal and human rights. This includes both the living and dead who require forensic interventions of doctors, nurses, police, social services, and the forensic sciences. Previously in the United States, those who survived criminal assaults, abuse, neglect, and liabilityrelated injuries were not provided the quality forensic assessment and protection of their legal rights as were those who died. Due to the lack of skilled forensic clinicians in the clinical environs, only the deceased were properly evaluated by the forensic pathologist. However, in other countries where forensic clinical intervention is managed by physicians known as forensic medical examiners (FMEs), there often remains a void in immediate response and state-of-the art skills. Because the FME is not in residence at the clinical facility, he or she must be located and respond to the emergency department, and it is not uncommon for all medical services, including life-saving interventions, to be withheld until the FME has arrived and collected evidence. In some countries, the patient is transferred to other hospitals and to different cities in search of clinical forensic services. On occasion, the patient dies during the interval between transfers, a situation referred to as “death by red tape.” Where the forensic nurse examiner is on staff on each shift, immediate forensic services can be provided without

delay. Critical forensic evidence requiring timely recovery and preservation is collected and secured without interfering with urgent medical care. Because the forensic investigation of trauma and the collection of evidence are not considered medical treatment, the FNE can provide forensic services within the boundaries of nursing practice, which includes documentation of trauma and collection of specimens. Specialized education and training are required along with essential continuing education, peer review, credentials, and professional organization membership. Thus, the FNE is qualified as an expert witness in courts of law. With the advances in contemporary medical and scientific technology, the need for victims to be provided with superior forensic services is central to the administration of justice. This text has outlined and identified the most significant fundamental knowledge for nurses who engage in clinical intervention and the scientific investigation of death in the clinical or community environs. This includes cases of sexual assault, child and elder abuse, domestic violence, motor vehicle trauma, gunshot and stab wounds, as well as neglect and violations of individual human rights; also included are the basics of evidence collection and preservation, photo documentation, legal aspects of forensic practice, and the application of nursing principles and philosophy to the law: forensic nursing science. There is no better way to appreciate the unique contributions of forensic nurses to the healthcare and the social justice systems than to walk among them and to relive their experiences. The reader of this book has the opportunity to take such a vicarious adventure with a journalist who has compiled the chronicles of pioneers and leaders of forensic nursing. Kelly M. Pyrek is neither a nurse nor a forensic scientist, but she made it a priority to learn almost everything about nursing’s newest specialty. She aptly demonstrates how forensic nurses work among law enforcement, legal, and forensic personnel, and what they bring to the table that is unique, socially relevant, and valuable. The author has immersed herself in educational ventures and stepped into the trenches with the best forensic nurse clinicians. Her findings, gleaned from interviews, observations, and journalistic investigations of actual cases, permit a glimpse into the virtual world of forensic nursing, replete with triumphs and tragedies that are typically associated with an emerging discipline. —Virginia A. Lynch, MSN, RN, FAAFS, FAAN International Consultant in Forensic Nursing Science Faculty of Forensic Nursing and Forensic Health Sciences Beth El College of Nursing and Health Sciences University of Colorado, Colorado Springs

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Preface Forensic science might be at the apex of its popularity among members of the general public who have demonstrated a keen curiosity, satiated by a growing amount of forensic-related television programming. At the time of writing in 2005, no less than half a dozen forensic-themed shows appeared on network and cable television. The studious Forensic Files shares space and time in America’s living rooms with the three “Hollywoodized” permutations of CSI: Crime Scene Investigation, and millions of people are tuned in to the exploits of the men and women who work as investigators, forensic scientists, and crime scene and lab technicians. From gritty to glamorous, from realistic to ridiculous, these shows have raised significant awareness of forensic science. Articles in the lay press have documented the “CSI factor,” in which an increasing number of juries know about and expect to examine the forensic evidence involved in criminal and even some civil cases; think Twelve Angry Men of today. This is a Law & Order generation; undergraduate and graduate programs are filled to capacity with eager young people dreaming of an exciting career in forensic science or criminal justice. Are expectations of the field romanticized and unrealistic? Yes, but big dreams and high hopes can turn into the next big theories that continue to propel forensic science from the rudimentary to the refined, as history has already demonstrated. There is a significant dearth of forensic practitioners to keep pace with growing investigative demands on the criminal justice system stemming from criminal activity, violence, injury, and death, so we must grow a new crop of highly trained, astute professionals versed in medico-legal principles and practices. It is this heavy investigative workload that, in part, opens the door for the heroes and heroines of forensic nursing. Nurses are not detectives, yet they possess an investigator’s sense of curiosity and intuition, as well as keen observation and analytical skills. Nurses are not forensic laboratory technicians, but they execute evidence collection and preservation with impeccable precision. Nurses are not scientists per se, but they endeavor to meet the same exacting standards, and to satisfy the rigors of science-based study within the confines of nursing practice. Nurses are not prosecutors, yet in some small way they share a desire to see justice served. Conversely, investigators, forensic scientists, lab technicians, and prosecutors do not have the in-depth medical knowledge and psychosocial skills inherent to nursing. However, with increasing admiration of the contributions forensic nurses are making, these professionals appreciate nurses’ ability

to understand and integrate nursing practice into medicolegal cases. Forensic nursing is the intersection of nursing and medical practice as applied to the law, hence it is very much a medico-legal discipline. In their forensic capacities, nurses assess, treat, and refer victims and perpetrators of violence, whose situations define the very essence of medico-legal investigation. These acts of violence include sexual assault, interpersonal violence, child and elder abuse, and assault of just about every sociodemographic group; they also see victims of motor vehicle accidents, product tampering, acts of terrorism, and other types of trauma. When serving as medico-legal death investigators, forensic nurses extend the nursing purview from the living to the dead, in investigating natural and suspicious or sudden death. Forensic pathologist Michael Baden, MD, once said to me, “Forensic nursing is a discipline whose time has come,” and forensic scientist Henry C. Lee once told me that forensic nurses were “absolutely essential.” Additionally, forensic laboratory directors Paul Ferrara and Barry Fisher have long respected forensic nurses for their professional prowess. These are noted and famed individuals whose opinions carry weight in the forensic science community; nurses must embrace these words of encouragement and cling to them as they continue to navigate uncharted territory in the clinical realm and bring their forensic skills to bear on health care cases of all dispositions. Besides championing forensic nurses, this book is designed to make a strong case for the important emerging specialty of forensic nursing and its contributions to the medico-legal community. The preponderance of violence and trauma, both accidental and intentional, issues new clinical mandates for the health care industry as these medico-legal cases present in increasing numbers. The World Health Organization (WHO) defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (Krug et al., 2002). In a 1996 resolution declaring violence a leading public health problem, the World Health Assembly called on the WHO to develop a typology of violence that characterized the different types of violence and the links between them (WHO, 1996). This typology divides violence into three broad categories according to characteristics of those committing the violent act: self-directed

violence, interpersonal violence, and collective violence. This categorization differentiates between violence a person inflicts on himself or herself, violence inflicted by another individual or by a small group of individuals, and violence inflicted by larger groups such as states, organized political groups, militia groups, and terrorist organizations. In addition, the nature of violent acts can be physical, sexual, psychological, or involve deprivation or neglect. Forensic nursing is the most appropriate response to the challenge of violence and its impact on public health, and its practitioners are in an ideal position to not only treat its victims and perpetrators, but also to assist in the collection and cataloguing of data. The government is recognizing that it needs to track epidemiologic information related to violent deaths. In fact, the federal Centers for Disease Control and Prevention (CDC) are calling violence—including the approximately 50,000 homicide and suicide deaths annually—a significant public health issue (CDC, 2004a). According to the CDC’s National Vital Statistics System, in 2001, almost 21,000 homicides and 31,000 suicides occurred, and almost 1.8 million people were assaulted. About 323,000 harmed themselves and were treated in hospital emergency departments. Additionally, in 2001, homicide was the second leading cause of death for people ages 10 to 24, and suicide was the third leading cause of death for people ages 10 to 24. The challenge is that current data do not provide all the information needed to accurately assess the factors surrounding violent deaths. Death certificates, for example, cannot link victim and suspect information. The CDC recognized that local, state, and national policymakers and program developers did not have comprehensive information about violent deaths, and that although state and local agencies have detailed information that answers fundamental questions about patterns and trends in violence, this information is fragmented and inaccessible. Creating a system to pool these valuable data would help answer such fundamental questions: • • • • •

Are violent deaths in schools increasing or decreasing? What proportion of homicides result from illicit drug deals? How often do murder–suicides occur? How frequently are homicides associated with child maltreatment? How serious a threat are mass killings?

To better develop answers to these questions, the CDC created the National Violent Death Reporting System (NVDRS), a state-based violent death reporting system designed to provide accurate and timely information to inform decision makers about the magnitude, trends, and characteristics of violent deaths, and evaluate and continue to improve state-based violence prevention pol-

icies and programs. The goals of the NVDRS are to do the following: •

•

• •

Link records from violent deaths that occurred in the same incident, which help identify risk factors for multiple homicides or homicide–suicides. Provide timely information through faster data retrieval. Currently, vital statistics data are not available until two years after the death. Describe in detail the circumstances that might have contributed to the violent death. Better characterize perpetrators, including their relationship to the victim(s).

Using these objectives, NVDRS illustrates a more comprehensive picture of violent incidents. The linked data provide law enforcement officials and death investigators a clearer picture of violent activity in their jurisdictions and will aid program operators to design and implement potentially successful prevention plans. Since August 2004, the CDC has been funding 17 states (Alaska, California, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin) to implement the NVDRS, and has also piloted the collection of data from state child fatality review teams in four of the states to better understand the value it adds to NVDRS. In late April 2005, the CDC released the first data from the NVDRS. Data reported by the first six participating states (Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and Virginia) show increases in suicide and homicide rates for the years 2000 through 2003. These data are in contrast to decreases in violent deaths reported in these states and nationwide from 1993 through 2000. Because this system only contains the first year of data in a small number of states, CDC officials say it is too early to determine how risk factors and trends might have changed in recent years. In 2003, homicide increased 4 percent and suicide increased 5 percent above 2002 rates in the six reporting states. Homicide rates among males under age 25 increased 18 percent in those states. “NVDRS puts us on the front line to collect rapid, reliable data to better inform our prevention strategies,” says CDC Director Julie Gerberding, MD, MPH. “With NVDRS, we can spot early warning trends for violent deaths and modify our prevention efforts. Among those warning signs are the role of alcohol and drugs in violent deaths, and how often a homicide is followed by a suicide.” The CDC established NVDRS in 2003 to address a crucial gap in understanding national and regional trends in violent deaths by combining relevant records into one repository of state-specific data. “This system provides states and communities valuable information that can be

used to develop and implement tailored violence prevention efforts,” says Ileana Arias, acting director of CDC’s National Center for Injury Prevention and Control. “The data help to identify potential strategies and also allow us to evaluate our current violence prevention efforts and determine if they are saving lives.” The NVDRS will document the circumstances of suicides and homicides to help identify and evaluate prevention opportunities. Each state collects detailed information about a violent death directly from the records of state health departments, medical examiners and coroners, and law enforcement, providing a clearer picture of the circumstances surrounding violent deaths at the national, regional, and state levels. Information such as a history of depression or a family dispute, gang activity, drugs, and other circumstances surrounding the violent death are recorded. Currently, 17 states participate in this state-based surveillance system. The next report expected late in 2005 will include the data from the initial six states as well as seven additional states (Alaska, Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin) that began collecting data in 2004. The final four states (California, Connecticut, New Mexico, and Utah), which began data collection in 2005, will not release any data until 2006. The CDC hopes to expand NVDRS to all 50 states so data can be compared across states and regions of the country, and to establish national violence-related data. Forensic nurses might one day become instrumental in assisting local jurisdictions in this data-collection process, especially as they continue to investigate regional and national violence-related trends, apply forensic nursing-driven knowledge to their interpretation of these data, and research and publish their findings for the benefit of the entire public health, forensic science, and criminal justice communities. Colleagues who knew I was writing a book about forensic nursing had expressed joy that, finally, someone was going to chronicle this exceptional nursing specialty in a more personal way than a traditional textbook, without sacrificing any of the studious thought and research on the subject. They also pointed to the fact that I am neither a nurse nor a scholar. True. I am an old-school journalist with more than 20 years of award-winning editorial investigatory experience backing my byline. I know how to research, how to ask the right questions and elicit truthful answers, and how to get to the heart of the matter. In regional and national newspapers, magazines, and trade journals, I have interviewed hundreds and hundreds of people, both laypersons and experts, in dozens of different fields. I have written perhaps a million or more words as I pursued the stories that made readers laugh, cry, think, act, and react. Telling the stories that no one else does is important to me, and that desire is the impetus for this project.

I discovered forensic nursing in 2001. It was late at night, without fanfare or any indication of the treasure trove that was about to yield its incredible wonders to me. I was researching via the Internet an article about the hottest nursing specialties when the term forensic nursing leaped from the screen of my computer monitor. OK, I thought to myself, I certainly know what forensic means, having nurtured an interest in this field for the past decade. I knew nursing quite well, having grown up as the daughter of a career nurse. What marvelous things, I contemplated, could happen when the two words were fused together? Hours passed as I searched for every shred of information I could find on the subject. Back then, there wasn’t much to be gleaned (today, however, an Internet search yields far greater and more current results, reflected in the fact more people are discovering forensic nursing for themselves), but I could fill in the blanks. I discovered that forensic nurses could, indeed, investigate medico-legal cases, and that they embraced the concept of living forensics, quickly dispelling the myth that forensic science is in the purview of the dead only. I discovered that a small, stalwart group of forensic nurses were making significant contributions to health care, law enforcement, death investigation, nursing jurisprudence, and criminal justice, to name just a few fields, and yet these nurses seemed to be the best-kept secret of the medico-legal world. The journey began in 2002 when I launched Forensic Nurse magazine; along the way, I met some amazing individuals whose passion for and dedication to the specialty were unrivaled. If there is one thing I know, besides journalism and publishing, it’s what makes nurses tick; after all, I grew up around nurses, and had a short stint in health care myself during high school and college. I know that nurses are traditionally overworked, underpaid, and continue to battle the “just-a-nurse” syndrome in their quest for personal and professional respect. They are breaking free of these stereotypical shackles, embracing the prestige of higher education and increased opportunities, demanding interesting assignments with impact, and tackling the difficult issues previously untouched by their medical and health care (and forensic!) colleagues. I know that nurses take every success and every failure very personally, and that they care very much about helping those in need, often at the expense of their own welfare. These nurses’ devotion to their practice, and particularly to the unique medical needs of the forensic patient, is manifested in how hard they work on behalf of their patients, and to a large degree, how much these nurses put their own needs behind everyone else’s. To this day, I can recognize a nurse from 100 paces away by that determined look on his or her face as he or she tries to make everything in the world right again. I don’t know if forensic nursing creates a new breed of supernurses, or whether these characteristics are already inherent in the nurses attracted to this specialty; whether

it’s nature or nurture, forensic nurses are extraordinary for several reasons. First, they continue to champion nursing at a time when nurses are stretched thin, underutilized, not given credit for their accomplishments, or abused by health care colleagues who are still not convinced of nurses’ unimpeachable status. The nursing shortage is happening for a reason, and although the majority of forensic nurses are veterans, the field is attracting a new generation of nurses. Only time will tell if they have the maturity, stamina, and skills of this specialty’s pioneers. Nursing is the oldest of all professions, yet many continue to take these special health care providers for granted. Imagine the Help Wanted ads for nurses: low pay, long hours, little respect. Who would still apply? The answer is more than ever, especially with the promise of change as forensic nursing science takes hold and changes minds. Second, these nurses are entering a specialty that is still considered to constitute vast stretches of health care frontier. Those in the know realize that all nurses are forensic nurses, and that nurses have been unwittingly practicing forensics all of their careers. Progressive thought has finally given forensic nursing a name and an identity that is still being tested, scrutinized, and questioned. Forensic nurses must consistently validate what they do and what they contribute to the health care and medico-legal communities. They are still perfecting their practice, identifying and filling voids in practice, defining and pushing the parameters of that scope of practice, and blazing new trails. It’s what they do best. Third, forensic nurses face a practice that is only for those with a strong stomach, a pure heart, and a quick mind. Daily, they face the ugliness of society, the monstrous acts humans inflict on each other, and the inconceivable actions that most see only in their nightmares. These nurses know they are speaking for the injured, the traumatized, and the dead in a time when there is an overwhelming need for the proper medico-legal process and for its most necessary by-product, justice; if not justice, at the very least, a structured, scientific approach to understanding the medico-legal aspects of the adverse, the unexpected, and the hard-to-contemplate. The cliché of nurses as part Sherlock Holmes, part Florence Nightingale is tiring because it suggests a vaguely cartoon-like depiction of a process that is very real and very serious to these nurses. It’s not a hobby or a fleeting interest; it’s a vocation worthy of the same respect as any other in the medico-legal community. These nurses mean business; they are on a never-ending quest to be science-based and taken seriously. They face enormous challenges in the future, even after overcoming significant barriers to practice. They face budget crunches and funding obstacles, questions of standardization of protocol and practice, quality issues, and gaps in training and education, among other important matters central to their effective practice. They lack a clearly defined career path, and they

are knocking on doors for jobs until their knuckles are battered and bloody. They also can be their own worst enemies if they allow themselves to be; nurses are said to eat their young, so even as the specialty struggles for acceptance and recognition, nurses must take great care not to internalize these struggles in the face of doubt or discrimination, or lack of leadership and vision both within and outside of the field. One would think this would be enough to scare off even the most determined of nurses, but they have a secret . . . they are addicted to the work, addicted to advocating through science for their patients, both living and deceased, because they know that no one else is as prepared and equipped to do so as they are. I should know. These nurses have welcomed this outsider journalist into their fold, and explained and discussed what they do for my professional edification and so I could better tell their stories to the world. They have taken me into their confidences, sharing their joys, their sorrows, their grievances, their worries, and their hopes for the field of forensic nursing. We have broken bread together, laughed and cried together, commiserated about the days that it felt too hard to proceed, and celebrated the times when it was easy and they could conquer the world. We have attended conferences together, enjoying a forum in which we could discuss, debate, and dream, all for the sake of advancing this wondrous nursing specialty. Detractors of forensic nursing are as plentiful as its supporters. Forensic nurses have as their champions their patients, family members, and an increasing number of enlightened members of the law enforcement, forensic laboratory, and legal communities, a trend that is hardwon and by no means complete or widespread. Until there is a forensic nurse in every health care facility, school, prison, and medical examiner’s office, and until the concept of living forensics is fully understood and accepted, there is much work to be done. It is the responsibility of every forensic nurse to tell his or her story, but better yet, to demonstrate his or her capacities and capabilities. That requires getting a foot in the door, and in many cases for these nurses, continually proving their mettle once they gain that coveted entry. Until it’s no longer lip service on the part of prospective employers, forensic nurses must push for equity, parity, and greater purpose and relevance in their work, seizing every opportunity to make a case for their presence. Through speaking with hundreds of nurses since 2001, and interviewing more than two dozen forensic nursing practitioners and other professionals for this book, I am convinced that this specialty will survive, thrive, and change for the better the way medicine interacts with the law. There is no limit to what forensic nurses can achieve, but they must be willing to jump those hurdles and break down those doors themselves. Arguably, in some places in this country, breaking through will be more difficult, as

stereotypes, gender biases, and lack of comprehension of the importance of forensic science principles in health care delivery continue to challenge these nurses. As many nurses have revealed in one form or another, the good days are very, very good, but the bad days are enough to make you want to turn and run. May every forensic nurse who reads this book have feet of stone, not clay, and may every forensic and medical professional come to appreciate nurses’ worth. Follow your convictions, and the respect will follow.

REFERENCES Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics System. 2004a. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System. 2004b. Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R., Eds. World Report on Violence and Health. New York: World Health Organization. 2002. World Health Organization. Global Consultation on Violence and Health. Violence: A Public Health Priority. New York: World Health Organization. 1996.

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Acknowledgments The forensic nursing and forensic science communities are graced by the presence of numerous exceptional individuals who give freely of their time and considerable expertise. I have the continued privilege of interacting with many of these people both professionally and personally, and I am indebted to them for sharing their wise and wonderful perspectives, their good humor, and most of all, their unsurpassed dedication to the kind of work that separates swiftly the weak from the strong. I wish to recognize the following people who have yielded gladly and enthusiastically their immense knowledge to me during the writing of this book, and during the past few years as the seeds for this project were being planted: Janet Barber, Virginia Lynch, Mary Dudley, Barry Fisher, Paul Ferrara, Georgia Pasqualone, Sharon Crowley, Nancy Cabelus, Diana Faugno, Candice DeLong, Meliss Vessier-Batchen, Melissa Becker, Bobbi Jo O’Neal, Rae Wooten, Susan Chewning, Patty Taylor, Mitch and

Tascha Spears, Robert and Debbie Smith, Mary Sullivan, Barbara O’Donnell, Cari Caruso, Linda McCracken, Cathy O’Brien, Constance Morrison, Joanne Archambault, Donna Bader, Linda Ledray, Colleen Carney Love, Prudence Schifley, Tara Ferguson, Kathy Delaney, Faye Batiste Otto, Gail Lindsey, Joyce Williams, Valerie Sievers, Jackie Palmer, Margaret Whelan, Maureen Jones, Sheryl Gordon, Rita Hammer, Julie Jervis, Yvonne McKoy, Barbara Cammuso, Katherine Ramsland, Mary Muscari, Mary Fran Ernst, Jim Hurley, Bruce Sackman, Brian Donnelly, Charles Wetli, Patrick Besant-Matthews, William Smock, Vincent DiMaio, Henry Lee, and Michael Baden. Thank you for sharing your brilliance with me. Having worked in publishing my entire life, I understand the significant effort required to escort a manuscript from concept to completion. I wish to express my heartfelt appreciation to the talented team at Taylor & Francis for believing in this project and making it happen.

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Table of Contents Chapter 1 Introduction to Forensic Nursing........................................................................................................................................ 1 Chapter 2 Forensic Nursing as Part of the Nursing Process............................................................................................................. 23 Chapter 3 The Mandate for Forensic Nursing................................................................................................................................... 33 Chapter 4 Forensic Issues in the Clinical Setting ............................................................................................................................. 43 Chapter 5 Forensic Nurses’ Medico-Legal Skill Sets: Observation, Documentation, Photography, and Evidence Collection ...... 81 Chapter 6 Sexual Assault ................................................................................................................................................................... 97 Chapter 7 Interpersonal Violence..................................................................................................................................................... 197 Chapter 8 Vulnerable Populations ................................................................................................................................................... 243 Chapter 9 Sexual Violence in the Military ...................................................................................................................................... 363 Chapter 10 Sexual Violence on Campus ........................................................................................................................................... 391 Chapter 11 Forensic Psychiatric Nursing and Corrections Nursing ................................................................................................. 401 Chapter 12 Medico-Legal Death Investigation.................................................................................................................................. 443 Chapter 13 Legal Nurse Consulting and Nursing Jurisprudence...................................................................................................... 507 Chapter 14 DNA Evidence and Medico-Legal Issues....................................................................................................................... 537 Chapter 15 Professional Issues: Forensic Nursing Education and Training..................................................................................... 589 Chapter 16 Professional Issues: Forensic Nurses as Entrepreneurs.................................................................................................. 617 Chapter 17 The Future of Forensic Nursing ..................................................................................................................................... 627 Index ............................................................................................................................................................................... 635

Dedication To my mother Judi Pyrek, who, as a parent and a nurse, taught me the meaning and value of hard work, dedication, and integrity; and to Tony Hettinger, who, as my best friend and soul mate, keeps me balanced personally and professionally. Life would have no meaning without you both. Thanks for always believing in me. With gratitude to Becky McEldowney Masterman for her support and encouragement, and for helping make a dream come true. This book is also dedicated to forensic nurses everywhere for their remarkable courage, their unsinkable convictions, and for their uncommon valor in the face of personal and professional duress, as well as to the patient populations they serve in the name of justice.

1 Introduction to Forensic Nursing CONTENTS 1.1 1.2 1.3 1.4 1.5 1.6 1.7

Who Needs a Forensic Nurse?.................................................................................................................................. 1 Introduction to Forensic Nursing .............................................................................................................................. 2 Clinical Forensic Medicine and “Living Forensics”................................................................................................. 2 The Development of the Forensic Antenna and Cultivation of the Index of Suspicion.......................................... 5 Investigation of Suspicious Injury or Death ........................................................................................................... 10 Investigating Undiagnosed Trauma ......................................................................................................................... 10 A New Nursing Specialty Emerges ........................................................................................................................ 11 1.7.1 What’s in a Name? ...................................................................................................................................... 12 1.7.2 Every Nurse’s Heritage as a Forensic Nurse .............................................................................................. 14 1.7.3 Clinical Forensic Nursing Practice.............................................................................................................. 18 1.7.4 The Role of Screening in Clinical Forensic Nursing ................................................................................. 19 1.7.4.1 Screening for Interpersonal Violence........................................................................................... 19 1.7.4.2 Screening for Child Abuse........................................................................................................... 20 1.7.4.3 Screening for Elder Abuse ........................................................................................................... 20 1.7.4.4 Screening for Rape....................................................................................................................... 20 1.7.4.5 Screening for Offenders ............................................................................................................... 20 References ......................................................................................................................................................................... 21 Recommended Readings ................................................................................................................................................... 22

1.1 WHO NEEDS A FORENSIC NURSE? An 81-year-old woman resides in a nursing home. She has mild dementia and suffers occasional spells of disorientation to time and place. While administering a shower, the woman’s caregiver notices contusions on her inner and outer thighs, and redness in her perineal area. She initially attributes the redness to irritation caused by the woman’s incontinence, but is puzzled by the bruise patterns. She searches the patient’s medical record, scanning for previous entries that document the bruises, but finds no explanation for the injuries or the redness. The caregiver decides that if no one else mentioned these findings, neither should she. How could she know that a male nurse on the night shift had been fired from his previous job for sexually fondling elderly female residents? A badly injured 58-year-old male victim of a motor vehicle accident lies unconscious in the intensive care unit of a 500-bed teaching hospital. The steady drip of the IV and the constant whoosh of the respirator are drowned out by the sounds of the chaotic shift change. While her incoming and outgoing colleagues engage in the end-ofshift report, the nurse slips into the patient’s room and sidles up to the IV pole. She removes a syringe and a small vial from her pocket and injects its contents into the IV

port. She tosses the syringe, the vial, and her disposable medical gloves into the trash can by the bed, and leaves the room silently and swiftly. How could the patient, immobile and sedated, know that the nurse had a penchant for mercy killing? A mother brings her 2-year-old boy into the emergency room of a busy metropolitan hospital one night. The boy’s face is flushed from crying and an elevated temperature, and the distraught woman is frantically trying to calm the youngster as she rushes toward a technician. As she shifts her child to her other hip and brushes the hair out of her eyes, she reveals a swollen lip and a pattern of red, blue, and purple bruising across her cheek. She catches the ER technician’s gaze and looks down, mumbling something about her son spiking a fever. She tugs at her son’s sleeve to hide the now-faint marks along the child’s forearm. Will the technician realize the woman’s fresh injuries and the boy’s healing injuries are classic indications of abuse? A body is discovered under some bushes by an earlymorning jogger. The partially clad young woman had been raped, strangled, and left for dead in a quiet wooded area thick with underbrush. Police officers scurry around the body in their haste to set up a command post, and one patrol officer didn’t notice that lodged in the sole of 1

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his boot is a small piece of cloth, matted with blood and hairs. He lumbers up a small incline to the squad car parked on a gravel road, where he absentmindedly proceeds to scrape mud off his shoes as he calls for the coroner. Different patients, different injuries, different environments; what all of these fictional yet representative scenarios have in common is the need for a nurse who is specifically trained to recognize and respond to potential medico-legal cases. Who needs a forensic nurse? As we will see throughout this book, any individual who is a victim of trauma, accident, abuse, or other malicious intent, needs a forensic nurse.

1.2 INTRODUCTION TO FORENSIC NURSING Until the last decade or so, forensic science had long been the exclusive domain of scientists, technicians, laboratory directors, members of law enforcement, and prosecutors, creating a medico-legal continuum that traditionally excluded health care in general and nursing in particular. Although not an intentional act of exclusion by the forensic science and criminal justice communities, inclusion of nursing was not considered to be an imperative, nor was it perceived as desired by clinicians. Medical practitioners, including nurses, have been characterized as being preoccupied with the living patient and disinterested in matters pertaining to the investigation of suspicious trauma and sudden or unexpected deaths, even in the clinical setting and elsewhere. Traditionally, health care providers have been responsible for assessing, diagnosing, and treating patients; in no way have they been expected to also investigate suspected or alleged criminal acts because that was within the purview of law enforcement only. More progressive thought in subsequent decades convinced select medical personnel to contemplate medicine and health care’s inherent role in medico-legal investigations. In many instances involving traumatic events, medical practitioners serve as first responders to individuals who are ill or have been wounded in some way. Frequently they are first to observe the presentation of injury, and during the administration of clinical interventions, they are able to further document signs, symptoms, and other physical, mental, and emotional manifestations of the patient in their care. These observations, documented in the patient’s official medical record, become part of the medico-legal process as soon as health care practitioners put pen to paper. Therefore, some astute clinicians wondered, why aren’t medicine and health care more closely aligned with law enforcement and criminal justice? The answer was, simply, that this alignment always has existed, but practitioners needed to

Forensic Nursing

understand and claim their medico-legal heritage to participate more fully. The application of forensic science to nursing, although considered still to be quite new and contemporary, has deep roots within the more traditional health care delivery model. For as long as victims of violence have reported to the nation’s emergency rooms, the health care system has required a method to treat and document these patients’ injuries. Although proper acknowledgment and handling of these medico-legal cases were lacking in the past, in the 1980s and 1990s, forward-thinking individuals recognized that forensic nursing is an important facilitator of medico-legal investigation. Lynch (1995, 1997) has described the highly competent, comprehensive approach forensic nursing provides to the equal treatment of the victim and the perpetrator of the pervasive violence, trauma, terrorism, neglect, abuse, and other forms of malfeasance encountered in 21st-century society. Sullivan (2005) says that clinical forensic nursing is one forensic nursing subspecialty that is underrepresented and not yet formally recognized within the general hospital setting. This subspecialty encompasses “a broad range of forensic knowledge and skills that may be applied to any patient care area within a health care facility.” She writes: The clinical forensic nurse serves as a role model in clinical situations by increasing staff awareness of the potential for forensic implications in everyday patient care as well as working hand in hand with those charged with investigating patient complaints, suspicious patient events, unexpected death, questionable trends, and emergency/traumatic patient admissions. In addition to fulfilling another critical link between the clinical arena and the judicial system, the clinical forensic nurse is in a position to provide vital protection to victims of foul play when they are at their most vulnerable. The importance of evidence recognition, collection, and accurate documentation is a means to an end for giving patients who are victims of violence, true holistic care, all of which are components of forensic nursing.

1.3 CLINICAL FORENSIC MEDICINE AND “LIVING FORENSICS” Smock (2003) states that forensic emergency medicine, also known as clinical forensic medicine, is “the application of forensic medical knowledge and appropriate techniques to living patients in the emergency department.” He explains that most trauma patients seen in today’s emergency department (ED) are not the victims of happenstance or accident, but of “malice and intent at the hands of assailants.” Clinicians must now consider the many details they once overlooked as vital evidence in these medico-legal cases. Smock, Nichols, and Fuller (1993) write, “What was once considered confounding

Introduction to Forensic Nursing

clutter that gets in the way of patient care (such as clothing and surface dirt) takes on a whole new significance when recognized for what it really is—evidence.” They add: Traditionally, the emergency physician has been trained in the provision of emergency medical care without regard for forensic issues. In the process of providing patient care, critical evidence can be lost, discarded, or inadvertently washed away. Patients then lose access to information that can be of critical significance when criminal or civil proceedings arise secondary to their injuries.

Forensic nursing takes its cue from clinical forensic medicine, first embodied within the concept of a “police surgeon” and now more commonly referred to as a forensic physician, which has its origins in the United Kingdom. The profession is supported by the Association of Forensic Physicians, which states that forensic physicians must be registered medical practitioners and, ideally, should have a higher qualification such as the diploma in medical jurisprudence. These physicians promote the discipline and knowledge of clinical forensic medicine and advancement in medico-legal knowledge in all its aspects as applied to the work of police surgeons. Eckert et al. (1986) defined clinical forensic medicine as the application of the principles and practices of medicine to the elucidation of questions in judicial proceedings for the prosecution of the individual’s legal rights prior to death. Smock points to a void in clinical forensic medicine in the United States, citing the work of early pioneers such as John Smialek, MD, and William Eckert, MD, who documented the lack of such forensic practice here when a successful system was blooming in the United Kingdom. In 1986, medico-legal expert Cyril Wecht, MD, JD, stated, “It’s a great shame and a source of much puzzlement why a group similar to police surgeons hasn’t developed here . . . I believe those persons with both medical and forensic training could remove much of the guesswork, speculation, and hypotheses from the disposition of accident or assault cases involving living persons” (Smock et al., 1993). In the United States, the first formal postgraduate program to educate the equivalent of the United Kingdom’s forensic physicians was held in 1990 as a two-day seminar sponsored by the Illinois chapter of the American College of Emergency Physicians (ACEP). Although this program did not take hold, another postgraduate training seminar was established in 1994 by the Kentucky chapter of the ACEP and continued through 1998. In “Development and Implementation of the First Clinical Forensic Medicine Training Program,” published in the Journal of Forensic Science, Smock et al. (1993) describe the creation of this first residency-based clinical forensic medicine training program and fellowship designed to address the unmet forensic needs of victims who are survivors of violent

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crimes and trauma. The Kentucky Medical Examiner’s Office and the Department of Emergency Medicine at the University of Louisville began training physicians to provide clinical forensic evaluations. The clinical forensic physicians evaluate adult and pediatric victims of blunt and penetrating trauma, as well as sexual and physical abuse, and collect evidentiary material when indicated. The development of a clinical forensic medicine training program and fellowship at the resident physician level is internationally unique, the authors say. Clinical forensic medicine is principally concerned with the provision of forensic medical services to the living and medical advice in the investigation of crimes. In other words, clinical forensic medicine is the branch of medicine that deals specifically with cases involving both legal and medical aspects of patient care. A forensic evaluation refers to the detection, collection, and preservation of evidence. Pattern-injury recognition, interpretation of injuries, documentation of testimony and injuries (including photography), reporting requirements, and regulations are all vital components of a forensic evaluation, but these issues are rarely discussed in most hospitals. Medical professionals working in prehospital care and acute-care settings are likely to encounter perplexing forensic issues related to child abuse, sexual assault, or unexpected child or adult death in their practice, so medical practitioners increasingly are being trained to handle these special cases. William S. Smock, MD, MS, FACEP, FAAEM, knows clinical forensic medicine. Not only is he the author of the definitive text on the subject, Forensic Emergency Medicine, but he wears many hats, including serving as associate professor of emergency medicine and director of the Clinical Forensic Medicine Training Program at the University of Louisville in Kentucky; serving as a police surgeon for the Louisville Metro Police Department; working as a forensic consultant for the Office of the Chief Medical Examiner; serving as tactical physician for the Louisville Metro Police Department and the Floyd County Police Department; and working as the medical director of the Sexual Assault Nursing Program at his university. Smock, whose interests include domestic violence, forensic reconstruction of injuries, gunshot wound injuries, and tactical emergency medicine, believes that clinical forensic medicine should be at the forefront of the attention of every medical practitioner at every health care institution across the country. Much the same can be said for forensic nurses. Smock says that emergency personnel, both by design and by default, evaluate and treat victims of violence, and that all of these kinds of patients “have injuries or conditions that have criminal or civil forensic medical implications and the prospect or specter of courtroom sequelae.” Forensic nursing is built on “living forensics,” a concept steeped in clinical forensic medicine. In 1987, Harry

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Forensic Nursing

C. McNamara, then the chief medical examiner for Ulster County, New York, defined it as the “application of clinical forensic medicine to victims of trauma involving the proper processing of forensic evidence” (Lynch, 1995). Essentially, forensic nurses are trained to identify, document, collect, and preserve physical evidence from victims of trauma presenting to the health care setting. Lynch (1997) explains that clinical forensic practice derives from the broader field of forensic medicine and is defined as “the application of clinical and scientific knowledge to questions of law and the civil or criminal investigation of survivors of traumatic injury and/or patient treatment involving court-related issues.” She adds that living forensic patients are the survivors of criminal or liability-related injuries that result in an investigation by a legal entity. Lynch adds, “No longer can health care providers work in isolation from the legal issues previously delegated to law enforcement. It is the responsibility of health care professionals to maintain a high index of suspicion and to protect victims.” Lynch states that nurses should provide leadership by routinely identifying, treating, and referring victims of abuse to the appropriate authorities. “To this end,” Lynch wrote, “it is necessary to establish and train professionals in the philosophy of living forensics, beginning with emergency intervention.” She adds, “Forensic nursing can provide an appropriate health care response to the sequelae of criminal and interpersonal violence.” Linda McCracken, RN, a nurse clinician and forensic nursing consultant in the emergency department of the Foothills Medical Centre in Calgary, Alberta, Canada, states: Health care and the law often become enmeshed during the critical moments when patient care supersedes the concern for social justice. Physicians, though supportive of the patient, focus their interventions on immediate lifesaving measures and in doing so often unwittingly destroy crucial evidence. Due to the nature of emergency clientele and the emergency care setting, there is a forensic opportunity for the emergency nurse to play an important role in the pursuit of justice in areas of crime and victimization.

She adds that the emergency nurse is usually the first to see the patient, first to talk with the family, first to handle the patient’s property, and first to deal with specimens and evidence. She adds, “The emergency nurse must be proactive in recognizing that any patient admitted to the emergency room with potential liability-related injuries, whether victim or victimizer, living or dead, is a clinical forensic patient.” McCracken, who is an active member of a number of trauma nursing associations and holds a certificate in forensic studies from Mount Royal College in Calgary, Alberta, Canada, says, “First and foremost, the emergency care provider must recognize that a potential foren-

sic issue exists.” She adds that potential forensic cases seen in the emergency room include individuals involved in motor vehicle accidents; attempted homicide or suicide; injuries involving firearms, knives, or other weapons; accidents (including fires, falls, or electrocution); work-related accidents; poisonings; overdoses or illegal drug use; sexual or nonsexual assaults; anyone in police custody for any circumstance; and sudden, unexpected death within or outside the health care institution. In the white paper, “Saving Lives, Saving Evidence,” McCracken writes: When we as emergency-care providers deal with the injured from car collisions, domestic/physical abuse, sexual assault, child or elder abuse or neglect, work-related injuries and/or the families of them all, we are practicing clinical forensic medicine. What is done, what is saved, what is charted, are all important and can make the difference in the end results of litigation/conviction, long after the patient has left the ER domain.

McCracken says that she saw other members of the multidisciplinary team “fumbling as to their roles when we all came together over one case. It was time for emergency-care providers, and other health disciplines, to do their part in narrowing the gap in the medico-legal process.” She adds: One way was to assure that we were not the cause of a miscarriage of justice because of what we documented, what we threw away or what we did with the patient’s belongings that could potentially destroy the evidence. I learned the importance of evidence: gross, transient, trace and informational, and the first step in learning how to keep evidence from being destroyed.

McCracken devised a mnemonic, the ABCs of clinical forensic nursing, to assist nurses with their medico-legal responsibilities: A = Assessment of the victim B = Bridge the gap; liaison with outside agencies such as law enforcement and the medical examiner C = Chain of custody; know the methods of evidence collection and establish continuity of evidence possession and disposition D = Documentation of findings E = Evidence F = Families; keep them informed G = Going to court; be prepared to provide written or oral testimony H = Hospital policies; know where and how to access your institution’s forensic protocols I = Index of suspicion; be aware of signs of abuse and violence

Introduction to Forensic Nursing

McCracken says: Trauma-care providers are very good at finding out what is injured. We excel in the “E” part of the mnemonic of trauma care: “Expose” the patient to see what is hurt. Unfortunately, we are also skilled at throwing the soiled clothing away, washing the wounds, applying our magic ointments, and making judgments and suppositions when we are not expertly trained in that field. There were no guidelines for us to follow regarding basic forensic evidence collection in the trauma room, no clear direction in the forensic aspect of care other than those involving sexual assault or child abuse. I saw firsthand the need for a collaborative, consistent approach, between all disciplines when dealing with victims/victimizers in the health care setting. First of all, I knew health care providers thrived on mnemonics, so why not put together another one, that being “The Forensic ABCs of Trauma Care.”

McCracken’s dedication to promoting forensic issues among nurses lies deep within her passion for the field. “Forensic nursing seemed to be a natural evolution in my practice as an emergency nurse,” she explains, “because I dealt constantly with victims of violence, work-related injuries, overdoses, organ donation cases, etc.” She says what prepared her best for the rigors of her work was early exposure to the courtroom: Having been subpoenaed to court on cases in which I was the nurse attending the client while in the emergency room, I learned the hard way, by experience, how my role had to expand. I saw the importance of thorough and concise documentation of patients’ statements and injuries. I developed a keen sense of intuition with each new case and recognized that critical thinking in the trauma setting included that “suspiciousness factor” when what I saw just didn’t match with what I was being told.

McCracken has worked as a nurse for more than 31 years and says: Experience has been my best educator. No courses existed in forensic nursing in my training days. After 24 years of working as an RN (at that time 19 years in the emergency setting), I piloted the first forensic health studies distance program at our local community college. I received a certificate of achievement in forensic studies from Mt. Royal College in Calgary, Alberta, Canada. Most additional aspects (especially forensic education within the trauma science) were self-taught through literature searches and forensic workshops. Basic nursing curriculums didn’t cover the forensic aspects of patient care. Forensic nursing is now an option in the nursing degree program and is not mandatory. I wasn’t prepared for my role as witness in court testimony, so I learned by repeated experiences in that arena. I didn’t understand

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injury patterns from a forensic standpoint other than those sustained from a medical standpoint, so I think nurses can be better prepared by incorporating forensic aspects of care within the trauma-care regimen, as well as have more in-service training as to the role of the bedside nurse in the court system.

McCracken believes that forensic nursing expands the traditional role of nursing by incorporating the forensic aspect of care into patients’ care plans. “I am really giving holistic care to my patients and assuring justice for society.” She adds: I feel as though my work is a vital link in the chain of justice, a member of a multidisciplinary team assuring that justice is served and those that cannot speak for themselves (like the children or the victims of domestic violence who are too afraid to report the abuse) are heard. My documentation, both written and photographic, tell the story and show the injuries. Even though by the time some cases finally get to court those injuries are healed, my written word is legal testimony for my patient.

1.4 THE DEVELOPMENT OF THE FORENSIC ANTENNA AND CULTIVATION OF THE INDEX OF SUSPICION Most nurses believe they are born with an antenna of sorts, which is able to guide them through clinical practice and help them determine what is right and what is not, whether it’s a decision, an action, a medical presentation, or a patient interview. Nurses have an uncanny ability to discern when something is not quite right; it’s a skill that serves them particularly well in the application of forensic nursing. Astute, well-trained nurses can identify suspicious situations that might fly under other health care professionals’ radar. Winfrey and Smith (1999) say, “When an individual nurse masters forensic content and incorporates it into clinical practice, forensic science can also serve as a framework for honing intuition by increasing the suspiciousness factor.” The intuition of an experienced, seasoned clinician, coupled with accurate assessment, is a powerful combination. Paul and Heaslip (1995) say that the practice of “critically noticing” on the part of health care practitioners is essential. Intuition is second nature to nurses, who instinctively know when something is amiss. Eason and Wilcockson (1996) say that intuition is a rational knowledge base from which appropriate action is taken. Mary K. Sullivan, RNC, CARN, MSN, BSN, says that nurses develop their forensic antennae as they mature in their nursing practice:

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Forensic Nursing

First and foremost, the nurse must be comfortable and competent in his or her area of expertise, having a solid base of experience from which to draw. In order to know when something is not right, the nurse must first know when something is right. And that definitely comes with experience. Over time, every nurse gradually develops a sense of what’s right and what’s not right with patients, or with the routine in any given area of nursing practice. If a nurse is able to tune out the white noise, and tune in to what is happening with the patient, he or she can pick up an incredible amount of information.

McCracken explains that a nurse’s index of suspicion is one’s intuitive, “gut” feeling based on a health care provider’s experience, education, and speed of reasoning. “This intuition signals that a particular patient or situation has potential forensic consequences,” she says. McCracken adds that the suspiciousness factor is a nurse’s “little voice inside his or her head.” She recalls a case that might never have been solved correctly had her forensic antenna not told her something wasn’t adding up. It demonstrated the lesson of not taking things at face value, especially when they tie into cultural biases. This particular case involved a Native American individual, and it was assumed that all Native Americans are drunks. Unfortunately, that’s the way people think. He was found in the downtown train station, lying at the bottom of the steps, with severe head trauma. He was brought in intubated and unconscious. Police weren’t dispatched to the scene, as the paramedics and the train system security staff deemed that this was just another drunk Indian that fell down 30 cement steps. Well, the suspiciousness factor arose in me. I was the documenting nurse for the case and I said to myself, “Well, isn’t that strange that the patient’s shoes are tied?” I had already saved all the clothing—I am known as the “bag lady” by police services. I considered the mechanism of injury and saw that there was no cement anywhere on the body or on the clothing, and his pants weren’t ripped; all of his injuries were from the neck up. I thought, “What did he do, bounce down the stairs on his head?” It didn’t add up. I knew something was wrong.

McCracken says a little bit of sleuthing was in order: I thought, “I don’t know who this man is, so I will play the role of the nurse and contact the police; I’ll say he is an unidentified person and family members need to know he has life-threatening injuries. So let’s call dispatch at the police and see if they will assist us in identifying this person.” I always emphasize to other nurses to identify the unknown, as you never know what other illnesses they may have, so it was a plausible excuse. I phoned the police dispatch, and it just so happened that the dispatcher was a woman who used to

be a unit clerk at the hospital with whom I used to work. I said, “I am calling because we don’t know who this person is and wondered if the police would have the time to come to the hospital. He has some identifiable tattoos, so maybe they can figure out who he is.” I said, “You’re not hearing this from me, but I don’t think he fell down the stairs.” So she dispatched police and I said to them, “At all of the train stations there are video cameras; maybe we can see something—did he trip and fall or was he assaulted?” They played back the videotape and it showed two guys hitting the patient’s head with baseball bats. And, he was already at the bottom of the stairs when he was assaulted. The case turned in an instant.

McCracken recalls another case in which experience and intuition kicked in. A man was found lying on a fresh grave in a cemetery, apparently the victim of a gunshot wound to the head. There again, suspicion kicked in because this guy had all of these lesions on his right arm that looked like skin-popping lesions, as if someone had been shooting up. I was assuming that he was left-handed because the lesions were up and down his right arm. But why is the gunshot wound on the right side of his head? It comes down to that forensic mindset. The police officer said that the man shot himself and they figured this was the grave of his girlfriend who had committed suicide. I said, “Out of interest, I lecture on forensic issues and I talk about bagging people’s hands to protect possible gunshot residue, and I didn’t see blood spatter or gunshot residue on his hand—has he got any?” He had nothing on either hand. The police officer insisted that the wound was self-inflicted. But even the physician said, “I am just charting one wound to the head—not even self-inflicted.” It must have been a half-hour later that the police officer was bragging to others that he used to be a paramedic and how he knew what he was talking about. He was bragging about how smart he was on medical aspects, and I caught him hovering over the right hand of the victim, sniffing his hand for GSR after all. Suspiciousness is a mindset that nursing practitioners have, that others do not. Fortunately, I think a lot more people are questioning what they see these days. They don’t have to become paranoid, but a little bit of forensic thought process is a very good thing. Having the suspiciousness factor is great, but health care personnel need to know what to do with it. They need guidelines to follow so that in the end, justice to the patient will be served, whether the person is the victim or the victimizer—it doesn’t matter, we must be able to assist in justice.

Georgia Pasqualone, MSN, MSFS, RN, CEN, DABFN, a clinical forensic nurse specialist in Massachusetts, is the personification of the modern forensic nurse

Introduction to Forensic Nursing

who wears many hats within her health care institution and her community. Several years ago she was designated as the hospital’s forensic nurse consultant. She carries a pager and is on call 24/7 for the ED and for the rest of the hospital when potential forensic cases present. She reports that her colleagues in the ED are starting to recognize possible forensic situations and are becoming comfortable with summoning her for consultation. At first, they were not recognizing things like child or elder abuse; in our community, things like that just didn’t happen. But after working with them and teaching them about forensic principles, they started recognizing that something was wrong. So they would call me and say, “This person has bruises all over and their story isn’t making sense.” I’d come down and take a look. I remember one time a novice nurse had a patient who had bruises. He called for me and said that something didn’t feel right; he wanted to file an elder abuse report but he wasn’t sure how to document his suspicions in the medical record. I took a look at the woman and I asked about the nurse’s findings. He told me about the bruises, and I said, “But you’ve missed one of the most important things.” He said, “What did I miss?” and I replied, “Look at her face very carefully.” He studied her for about five minutes; he didn’t see it immediately, but then bingo, he noticed that her eyebrows and her eyelashes were singed. So not only was it abuse, it was neglect because she had been smoking with the oxygen cannula in her nose and her son was allowing her to do this. She could have lit herself on fire. So I am there to help nurses recognize some of the minute details their inexperienced eyes haven’t picked up yet. But they are learning to look a little more closely at what is in front of them and slowly they are feeling more proficient at noticing the little things.

Pasqualone says that part of her responsibilities include educating colleagues in the ED about forensic principles. She says that in Massachusetts, there are not enough sexual assault nurse examiners (SANEs) to go around, so she has taken it upon herself to train ED nurses in how to perform a sexual assault examination: I’ve taught them how to do the rape kit, how to fill out the paperwork properly, and I wrote up a two-and-a-halfhour continuing education program for all of the ED nurses in my hospital and made it a competency. Everyone viewed a training video, and they all had to practice with the rape kit, and now, if they have any questions, I leave the training video in the ED; all they have to do is throw it into the VCR and they can follow along with the videotape when performing the sexual assault kit.

With each bit of training, Pasqualone says, ED personnel are becoming more cognizant of medico-legal issues. “Little by little, they started recognizing forensic cases,” she confirms.

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We don’t take gunshot wounds here, as they are automatically routed into Boston, but we do get cases such as burns and stab wounds. ED personnel are becoming more aware of the statements which they need to document in the medical record, as well as the evidence which they need to collect and package. But it’s been a very slow process due to the nature of the ED. It’s a difficult crowd to get all in one spot at any one time. You have to catch them for 10 or 15 minutes at a time because they won’t sit still. They are way too tired and too busy to come in before work or to stay after work and they are so exhausted.

Pasqualone plans to hold a forensic skills fair sometime in 2005 to reach these busy health care professionals: They will be able to learn how to recognize evidence, how to bag it, label it, and photo-document it. My other goal for the year is to initiate a comprehensive photo-documentation policy and protocol in the ED along with teaching them how to use a digital camera. I think I have figured out how to get past the question of manipulation; a new generation of printers allows the user to simply lock the camera on top of the printer, push a button, and there’s your 4-by-6 print which can go right into the medical record.

She says that anything that makes medico-legal documentation easier for rushed ED personnel will benefit patients, health care providers, and the institution itself. She includes on the list addressing any forensic-related protocols that might be out of date, incomplete, or nonexistent: Prior to my arrival, our hospital had what they called a forensic policy, but it’s not what you think. This policy only involved patients who came into the ED in police custody. That was then; with greater forensic awareness and training among personnel in the ED, now, if you ask nurses and physicians what our forensic policy is, they’ll say excitedly, “That’s the part about sticking evidence in a bag and sealing it!” And that tells me we’re making real progress.

One of the basic tenets of the concept of living forensics, especially in the ED, is the “body as the crime scene”; that is, any injury suspected to have been caused by violence, abuse, neglect, assault, accidents, work-related injuries, or other circumstances of a medico-legal nature. William Smock says there are a few simple steps clinicians can take to ascertain if an injury is accidental or inflicted. They should first determine if the injury is consistent with the history supplied by the patient. If the patient says she fell, do her injuries suggest a defensive posture or signs of a struggle instead? Clinicians should also be aware of pattern injuries, which are epithelial imprints of weapons that are consistently reproducible.

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Forensic Nursing

For example, an injury produced by a linear object such as a baseball bat or a broomstick will generally produce a distinctive mark with central clearing surrounded by parallel linear contusions, essentially an outline of the shape of the weapon. These contusions are created when blood beneath the object creating the impact is pushed up and out. In suspected domestic violence cases, clinicians might see marks made by a common linear object, the human hand. A victim who might have been grabbed forcefully might exhibit oval clustered contusions representing fingertips, usually found on normally protected parts of the body such as the inner arm or the inner thigh. Ropes, cords, belts, shoe soles, and the like will also leave distinctive patterns on the skin. One of the most celebrated cases of pattern injury was a partial license plate number imprinted on the legs of a victim of a hit-and-run motor vehicle accident. Burns from a cigarette, a curling iron, water splash, or immersion can cause thermal injuries. For instance, an immersion burn features a sharp line of demarcation between unburned and burned flesh. These kinds of injuries are particularly suspicious when seen in the very young or in the elderly. Janet Barber, MSN, RN, a clinical nurse specialist in Indiana, says it takes discernment to be able to pick up on the clinical subtleties that separate suspicious situations from natural circumstances: Some nurses really want to develop that kind of a forensic antenna, while others don’t want to think that every death or injury occurred because of malfeasance or intent to harm. There are some nurses who cannot accept as an operating principle that there is no such thing as a natural death. Nurses must question everything they take in with their five senses, and if they don’t, they will miss something critical. I believe that some nurses are better than others at developing a forensic intuition or instinct. They are constantly on the uptake of everything around them. Those individuals who are good forensic nurses are the individuals who are good psych nurses or good ICU nurses or good ER nurses—these are people who don’t miss very much. They take in information with their eyes, their ears, their nose, their sense of touch . . . they are constantly pulling in information. There are some nurses who are content to simply go through the motions of passing out meds, doing treatments, reading data off of monitors and putting it in the chart, and that’s it. Forensic nurses are not content with that. They have to be the ones who raise the extra questions, who go the extra mile to solve a problem, and who don’t take anything at face value. They are the ones who say to themselves, “I have to gather more data, I have to understand this, I have to be able to put it all together.” Why do some people have that and others don’t? I think forensic nurses do what they do, knowing that they, and their patients, are on the edge between life and death; that everything matters, and every little detail requires scrutiny. They don’t take anything for granted, and they accept a higher level of responsibility

in doing so. If you notice the kind of people who are attracted to forensic nursing, you’ll see that they are not people who are just willing to grind through the day. Most of them are pretty extraordinary.

Barber emphasizes that even forensic nurses in training display a curiously perceptive sense of intuition. Barber, who teaches an online forensic nursing program, says she sees promise in young nurses who are beginning to sharpen their instincts. I have people from all over the world in this course, individuals of all ages and all specialties, and one of the common threads is their resourcefulness. I give them case studies involving various forensic nursing scenarios, and while my students don’t necessarily have education about all of these elements, they are consistently able to think through the scenarios based on their gut instincts. I’ll say, “You are planted in this particular scene. What would you be concerned about, what things would automatically be there, and how would you approach the circumstances?” and they are able to think through the exercise and come up with some amazing ideas that made me think to myself, “Wow, I wouldn’t have thought of that.” This kind of critical thinking and problem solving is essential to forensic nursing. This discipline requires nurses to function way beyond the basic level of nursing practice. If you want to be a nurse who functions at the basic level, you will not be a good forensic nurse; forensic nurses must delve below the surface, they have to ask the hard questions, they have to go where no one would go ordinarily. They really have to push the envelope. Some nurses are willing to do that, and if they are, they’re great forensic nurses, but if not, they lack the drive needed in this challenging nursing discipline.

This zeal will propel a forensic nurse forward along a professional path that might invite criticism or cynicism from medical colleagues who understand neither the tenets of forensic nursing nor the mandate for its existence. Says Barber: I believe there are situations where forensic nurses are ostracized or labeled as a nut case by their co-workers who haven’t bought into clinical forensic nursing. When forensic nurses say, “I’m sorry, I simply cannot take that at face value,” other nurses may be thinking, “Why are they splitting hairs?” Or they may think the forensic nurse is casting some kind of doubt on their performance or their word, and they get defensive. The forensic nurse was simply being thorough in an assessment of the situation, for the patient’s sake.

As a retired colonel in the nursing corps of the U.S. Air Force, Barber draws on a tactical allegory to illustrate her point:

Introduction to Forensic Nursing

It’s simply good science to question everything. In every aircraft incident in the Air Force, there is an investigative team that combs through the wreckage and goes through every detail for reconstruction purposes; no one thinks anything about that because it’s automatic, standard, everyday practice. But in hospitals, it has not become everyday practice; when somebody dies suddenly in the intensive care unit (ICU), nurses say, “Well, we just had a sudden death, that’s the way it goes.” But if they don’t investigate it, they’ll never know that the patient was electrocuted by their monitor, or a family member poisoned the patient, or someone plugged their trach tube, or whether their ventilator malfunctioned . . . it’s never been popular to even ask these kinds of questions. It’s usually a matter of, “Well, the patient died, let’s get them ready for their family to come and see them,” or “Let’s prepare them for the morgue and move on.” When clinicians start dealing with death scenes in a new way, that’s anxiety provoking for nurses who are not open to forensic nursing concepts.

Barber points to a nurse who traveled to Southeast Asia to assist with humanitarian and medical efforts in the wake of the tsunami that struck in December 2004: She’s operating as usual, when suddenly she starts noticing that there is trafficking in children, orphans are disappearing from what everyone felt were safe havens, that people were stealing rationed items and selling them . . . suddenly the nurse realizes the forensic implications, and her role changes. It’s the same in any hospital. You become a detective of sorts, and you begin looking for any irregularities. In cases of potential bioterrorism, for instance, the first patient who comes into the ER who has trouble breathing and has a weird rash, says, “I was walking down the street and having trouble breathing and I noticed my arms breaking out and I am coughing like crazy.” The first patient who comes in with those signs and symptoms is an isolated incident and you don’t think anything about it. But when the second and third patients come in with the same complaints, you begin to say, “Wait a minute, this is a pattern.” The difference between a forensic nurse and other nurses is that with the very first patient, they begin to say, “Wait a minute, this is a highly irregular presentation without any provocation. I wonder if . . .” and so they begin to initiate better surveillance early because they have that sixth sense telling them something might be amiss. They don’t assume anything, but if they can’t account for why something is occurring, there might be something highly irregular they need to deal with. In cases of possible terrorism, there is a huge opportunity for forensic nurses because of their powers of intuition and observation. When a patient who has been in a bomb blast presents to an ER, how do you know from which direction the blast came? Well, if you do irrigations of the ears, nose, and mouth, and you notice there are more chemical materials returning from the right ear canal than the left ear canal, chances are the bomb was to the right of the patient when it blew up. Forensic nurses are con-

9

stantly thinking about these kinds of variables because they have been well indoctrinated into such details. I think other nurses go through the motions and they don’t necessarily put the pieces together. It’s not only the clinical procedure, it’s a different thought process entirely.

Barber says she believes awareness of forensic protocol on the part of nurses is improving, due in part to the saturation of forensic science in the popular culture. It is beginning to sink in and influence nurses very subtly to the point they may say, “Wait a minute, I am in a position to be the key person in recognizing a potential forensic case and I’m on the first line of defense.” I think the media has done a great job in helping to zoom in on the fact that it was a nurse that discovered this irregularity, or it was a nurse that put two and two together and got this information and began to develop suspiciousness about it. I think nursing organizations like the Emergency Nurses Association (ENA), the American Association of Critical Care Nurses (AACN), and the International Association of Forensic Nurses (IAFN) have continued to send the message about forensic protocol and little by little it’s taking hold. I teach an online course for the University of California and in the last two or three courses, most of the students have not been ER, trauma, or ICU nurses per se, but they have been labor and delivery or pediatric nurses; they are seeing the need to understand forensicrelated issues such as infant abduction, or why people abuse their children. They are saying to themselves, “I have to get a handle on how would I recognize an unhealthy family situation that might signify that this child is very likely an abuse case.” I think these nurses are beginning to see that they have a key role in protecting patients by being educated, because the more they know, the more savvy they are going to be about seeing unusual things. Several of these nurses have said things like, “I would never forgive myself if I missed a case of infant abduction that was occurring right in front of me,” or “I would never forgive myself if I sent a patient home from the ER after which the parent killed the child.” I think they feel an intense responsibility to get educated so they don’t inadvertently allow or facilitate wrongdoing. That’s very important to most nurses. Students repeatedly tell me, “I used to not believe that things like infant abductions and elder abuse happened, but now, I want to know how I can help prevent it.” They want to become better educated about these medico-legal issues.

Connecticut forensic nursing educator Barbara Moynihan, RN, PhD, APRN, associate professor of nursing at Quinnipiac University, suggests that nurses need to pay attention to their intuition: They need to learn it’s OK to trust their gut feelings or follow an educated hunch. If something just doesn’t seem right, you’re probably on track because there may be cause to be concerned. Forensic nurses are trained to look at every situation through a forensic lens; they will identify

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Forensic Nursing

situations they might not have identified had they not looked through that lens. Potential forensic cases can be subtle, so nurses need experience in diverse areas of forensic theory and practice so that clinical experiences are consistent with and integrate didactic knowledge. To better understand law enforcement issues, clinical experiences should include time with law enforcement in a variety of settings. To better understand death investigation, the medical examiner’s office is a valuable site in which to gain this critical knowledge. To better understand elder abuse, experiences are planned with adult protective services and the state’s attorney’s office. These experiences facilitate a better understanding of forensic concepts and practice.

Moynihan adds that her students embrace quickly the concept of living forensics and hone their skills at looking through the forensic lens. “They enjoy the challenge of examining and reviewing clinical cases. If they miss something, we research the situation, and frequently that ‘Aha!’ moment is experienced. Student nurses are eager to absorb and assimilate new knowledge and integrate this knowledge into practice.”

1.5 INVESTIGATION OF SUSPICIOUS INJURY OR DEATH Suspicious injury or sudden death cases are like jigsaw puzzles to forensic practitioners eager to connect what they hear from patients to what they visualize. “The responsibility of the forensic nurse is to use all senses when examining injuries,” says Mary Dudley, MD, MSN, RN, chief medical examiner/forensic pathologist and district coroner for the Sedgwick County Regional Forensic Science Center in Wichita, Kansas. “What they have, what they see, documenting it very carefully, listening to what the individual has to say, listening to what is said from all different aspects, observing body language.” Dudley says that at least 80 percent to 90 percent of cases that present have some forensic implication, or any case where clinical medicine would interface with the law. “I think it’s very important . . . that the emergency room nurses have forensic training, so that they are able to identify and know what to look for on these different types of injuries that they may see,” Dudley says. “The interview process is really powerful because you can read people as to what they might be trying to mislead you on,” says Bobbi Jo O’Neal, RN, BSN, F-ABMDI, deputy coroner at the Charleston County, South Carolina Coroner’s Office: Most people aren’t trying to do that; most cases that we do are natural cases, they’re not the traumatic homicides that make the paper. But the ones that are the traumatic homicides are the ones where they’re trying to mislead you. If you’ve done lots of interviews where they’re nat-

ural and you see how people act when they’re not trying to hide something, you can pick up when people are misleading you. As a death investigator, the first thing that I’m going to do is look at the body and make my own assessment of what I’m seeing. Then we talk with the family, or whoever those individuals may be. From our perspective, we’re not going to tell them what we’ve found. We want them to say it to us. We want them to tell us what happened and then compare the two.

Charles Wetli, MD, chief medical examiner in the division of medical-legal investigations and forensic sciences in the Sidney B. Weinberg Center for Forensic Sciences, advises clinicians to be open to alternate explanations for injury when assessing a potential forensic case. “Make sure you keep an open mind, and don’t become prejudiced about things.” Wetli says: Sometimes the cause of a car crash is a bullet in the chest. Or the fire is started to cover up a homicide. Those kinds of things have to be kept in mind. You have to think dirty in these situations. Everything must correlate. If not, then you have to go back and start putting the pieces together and continue your investigation. You must approach the autopsy with much more intelligence, to answer questions that are going to be asked anywhere from the next day to five years later. I think the art of forensic pathology or forensic nursing is going to be to document things now in anticipation of questions that won’t be asked for maybe three or four years down the road. It’s your one chance to document everything. If questions do come up, you can go back to the file and look at the photographs and the diagrams and answer those particular questions that you have.

1.6 INVESTIGATING UNDIAGNOSED TRAUMA Lynch (1995) advocates a systematic approach to investigating undiagnosed trauma. The first step, she says, is the evaluation of wound pattern characteristics, a process aided by detailed documentation of the appearance of the wound, followed by determination of the type of weapon used to inflict the injury. These wound characteristics, however, Lynch says, constitute evidence that might be obscured by emergency trauma care, so nurses should take great care to differentiate the two. Documentation should include a description of the injury, the location of the injury, and approximate measurements of wounds, supplemented by diagrams, body maps, or photography to assist in reconstruction of injury patterns if the case goes to court. “For patients who survive, or whose wound is excised or extended surgically, later reconstruction of the injury is not possible,” Lynch writes, explaining that

Introduction to Forensic Nursing

reconstruction becomes especially important when the patient lives for an indefinite period and later dies as a result of the injury. “Treatment procedures and the natural healing process alter the condition of the wound, thus eliminating the possibility of determining if the wound was inflicted with a single or double edged blade knife, an entrance or exit gunshot wound and so forth.” Lynch adds: Nurses should have an accurate knowledge of the types of injuries generally resulting in medico-legal patients and should be familiar with the appropriate terminology. Failure to recognize and describe injuries has confounded the testimony of victim and perpetrator as a defense strategy in the courtroom. The nurse not only appears unprofessional, but a serious crime may go unpunished.

Lynch believes that nurses’ involvement in medicolegal investigations extends beyond the ED management of the patient, and that their responsibilities encompass physical evidence documentation and collection, and maintenance of the evidentiary chain of custody. “By implementing forensic protocol that emphasizes cooperation with the criminal justice sector, nurses are initiating a critical link in trauma systems that will provide for improved medico-legal outcomes,” she writes.

1.7 A NEW NURSING SPECIALTY EMERGES If physicians can engage in clinical forensic medicine, so too can nurses demonstrate their medico-legal capacities and expertise, for the benefit of living patients and decedents. It is this latter patient population, however, that has generated much speculation and surprise on the part of medical colleagues and uninformed laypersons. A very small number of nurses recognized this unparalleled opportunity for service to an unmet clinical need, and began to propose and describe the practice of clinical forensic nursing. In 1992, the IAFN was created to help support this newborn nursing specialty; today, the IAFN represents approximately 2,500 forensic nurses. Virginia A. Lynch, MSN, RN, a founding member of the IAFN and one of the first nurses to use the term forensic nursing, defines it as “the application of clinical nursing practice to the assessment and care of trauma survivors, or those whose death is pronounced in the clinical setting, including the identification of previously unrecognized or unidentified injuries, as well as the proper collection, processing, and preservation of forensic evidence.” Lynch (1995) writes, “Forensics traditionally was associated with death and homicide. Today, trends in hospital and community health care have broadened this specialty to include identification of previously unidentified trauma and the collection of evidence from living

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patients.” Lynch explains, “Violence and its associated trauma are widely recognized as a critical health problem . . . Forensic nursing represents a new era of nursing practice that is evolving in direct response to the sequelae of criminal and interpersonal violence.” She writes, “The application of the principles and standards of the forensic specialist in nursing has been recognized as a vital new role in trauma care in the 1990s,” and adds that every day, nurses encounter “the results of human behavior extremes” such as abused children; individuals suffering from blatant neglect and maltreatment or selfinflicted injury; and victims of firearm injuries, knife wounds, and other assaults. “As trends in crime and violence change, new antiviolence legislation is being implemented; consequently, new personnel resources are required to ensure that these legislative mandates are effectively meeting the needs of society.” Lynch describes the role nurses play in the medicolegal process: “Nurses have been challenged to share responsibility with the legal system to augment the resources available to patients with liability-related injuries, crime victims, and perpetrators or suspects in police custody.” She describes a mutual responsibility concept that represents a new perspective in the holistic approach to legal issues in patient care. “There has been strong support for this concept from those who recognize the amount of knowledge required to go beyond the traditional treatment of crime victims and fill a greater role through forensic expertise in health care.” Forensic nurses say the general public and the majority of health care professionals misinterpret the meaning of the term forensic. Taber’s Cyclopedic Medical Dictionary defines the term, stemming from the Latin word forensic, meaning “a forum,” as “pertaining to the law,” specifically, to public debate in courts of law. Black’s Law Dictionary (Garner, 2001) defines forensic as “used in or suitable to courts of law or public debate.” Supporting the concept of living forensics, Lynch (1995) writes, “Any subdiscipline of science that practices its specialty within the arena of the law is practicing the principle of forensic science. Anywhere the world of law and the world of medicine collide, a medico-legal or forensic case occurs.” She explains that traditionally, the term forensic carried with it a connotation of death or homicide, an association made in medical practitioners’ and laypersons’ minds due to pervasive attention to forensic pathology, the medico-legal investigation of death. Contrasted with forensic pathology, or a concern with the dead, is the aforementioned concept of living forensics, which Lynch describes as “a new trend in clinical and community health care that involves the awareness and recognition of unidentified or previously unrecognized trauma and the collection of evidence from living patients.” Lynch adds, “Survivors of trauma requiring the investigation of injuries are the concern of the clinician, not the pathologist,

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Forensic Nursing

although well-trained and experienced forensic pathologists are often willing to assist. Clinical forensic practice is becoming recognized as an essential component of health care in the United States and Canada. Indeed, it has been a respected discipline in public health for 200 years in other parts of the world.” If one accepts these definitions, one must therefore see that living forensics encompasses clinical forensic nursing. In 1992, the IAFN stated: Forensic nursing is the application of the forensic aspects of health care combined with the bio/psycho/social education of the registered nurse in the scientific investigation and treatment of trauma and/or death of victims and perpetrators of violence, criminal activity, and traumatic accidents. The forensic nurse provides direct services to individual clients, consultation services to nursing, medical and law-related agencies, as well as providing expert court testimony in areas dealing with questioned death investigative processes, adequacy of services delivery, and specialized diagnoses of specific conditions as related to nursing.

In several books and white papers, Lynch has outlined her vision of forensic nursing, which she sees as a natural progression of a nurse’s education, training, and deep perception of how nursing and health care intersect squarely with the law, hence the use of the term medico-legal investigation, which is synonymous with clinical forensic nursing and related activities of trauma, accident, and death investigation. Lynch has pointed out that in a traditional nursing role, nurses care for patients from birth through their life span, and in the medico-legal role, nurses follow the continuum all the way to the patient’s last chapter, death. Lynch writes, “When one considers the many cases of death that occur in the clinical setting that fall within the jurisdiction of the medical examiner or coroner, it is vital that clinicians are skilled in the documentation and preservation of evidence related to those cases.” She explains that nurses are frontline health care providers who are usually the first to interact with a patient and the corresponding evidence, even before law enforcement becomes involved in the case. She further asserts that forensic nurses have earned their rightful place in the medico-legal community. Lynch (1997) writes, “Criminalists and pathologists alike have identified nurses as a previously untapped resource to the forensic sciences, particularly in the investigation of injury and death. With the evolution of this new practice arena in clinical nursing, the role of the forensic clinical nurse specialist is emerging.” She adds that these nurses work in the clinical setting as well as in the community, and that “these individuals will become the designated clinicians in the assessment, treatment and referral in cases of physical assault, homicide or catastrophic accidents.”

Canadian forensic nursing educator Arlene KentWilkinson, RN, BSN, MN, has assembled the definitions of a number of forensic nursing specialties, including clinical forensic nursing, forensic correctional nursing, forensic ER nursing, forensic geriatric nursing, forensic legal nurse consulting, forensic mental health nursing, forensic investigator nursing, forensic examiner nursing, forensic occupational therapy, forensic pediatric nursing, forensic psychiatric nursing, and sexual assault nursing.

1.7.1 WHAT’S

IN A

NAME?

Forensic nursing is a broad term with which medical colleagues and laypersons alike still struggle to capture the full essence of the inherent responsibilities and roles. It is a collective noun that encompasses a multitude of nursing subspecialties in a variety of clinical and institutional settings. The degree to which persons try to comprehend the breadth and depth of forensic nursing is reflected in the field’s equally difficult struggle to adopt uniform occupational titles. Until laypersons, health care professionals, and colleagues in the forensic community recognize, understand, and embrace the meaning of forensic nursing, the title of forensic nurse is not entirely meaningful. Until forensic nursing titles become more than just words on paper and reflect a critical mass of evidence-based practice, they will not be given credit where it is long overdue. In the meantime, however, individuals in the forensic nursing community are eager to define themselves with titles that accurately reflect their clinical responsibilities and their passion for their unique and challenging profession. As will be explored in Chapter 6, one of the earliest incarnations of forensic nursing is the SANE. According to various members of the IAFN, before the organization’s creation in 1992, forensic nurse examiner programs were developed independently, operated autonomously, and used different terminology to define this new nursing role. One of the earliest programs in Minneapolis used the title of sexual assault nurse clinician (SANC) to denote a clinical nursing role that surpassed examination of the sexual assault victim. The SANC broadened the continuum of services provided to sexual assault victims, emphasizing crisis intervention and supportive counseling in the ED environment and continuing with follow-up counseling by nurse counselors. Another early program in Memphis used the SANE acronym. Other, newer programs have adopted the title of sexual assault/forensic examiner (SAFE) or forensic nurse examiner (FNE). According to the IAFN, a program in Minnesota selected the title of SAFE because it desired to move beyond examination of sexual assault victims exclusively to the completion of evidentiary exams on domestic abuse victims, accident victims, and other populations where forensic evidence collection could be critical to the medico-legal process. At the October 1996 IAFN annual meeting, the council representing SANEs

Introduction to Forensic Nursing

voted on the terminology it wanted to use in the standards to define this new position. Although there were some dissenting votes, the overwhelming decision was to use the title of SANE. Forensic nurse specialist. Forensic nurse investigator. Clinical forensic nurse specialist. Forensic nurse examiner. It might be a matter of semantics to members of the larger health care and scientific communities, but these distinctions are important to the men and women proudly fulfilling these roles. Sullivan (2005) writes: As this specialty continues to evolve within hospital and clinical settings, the impact of clinical forensic nursing practice is being felt in many of the patient care areas to which nurses are routinely assigned. These nurses put on their “forensic caps” and apply this expertise to a practice that might have become routine or second nature. They now see routine patient care assessment and health care delivery in a whole new way. A nurse does not have to leave the bedside, the outpatient clinic, the nursery, or nursing home care unit to be a legitimate forensic nurse. Although specific titles and position descriptions have not been established, several roles appear to be emerging that constitute specific forensic nursing responsibilities. Some of these roles overlap.

Forensic nursing encompasses the subspecialties of clinical forensic nurse specialist, SANE, forensic nurse death investigator, correctional nurse, forensic psychiatric nurse, and many other disciplines that fall under the umbrella of forensic nursing. Sullivan adds, “There are as many combinations of how nurses fulfill their traditional and forensic nursing practices as there are individual nurses.” Sullivan (2005) writes: The clinical forensic nurse (CFN) who chooses to practice exclusively in the patient care setting brings together a combination of expertise that includes traditional nursing knowledge as well as skill sets that borrow from the SANE, death investigator, and legal nurse consultant. Skill sets include specific techniques for evidence collection and safeguarding as well as an understanding of the essential steps for maintenance of the chain of custody. There are also documentation requirements that include fundamentals of forensic photography. Forensic personnel must also be facile in the use of medical records and other source documents and may need to interpret their relevance to nonmedical personnel involved in the investigation.

Sullivan observes that four distinct roles are evolving: the clinical forensic nurse provider, the clinical forensic nurse examiner, the clinical forensic nurse specialist, and the clinical forensic nurse investigator. Sullivan explains that while the clinical forensic nurse provider primarily serves in a caregiver role, “this nurse

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has obtained education and training in the forensic science disciplines and applies this expertise in patient-care scenarios.” Sullivan writes: Forensic science principles and the art of “critically noticing” is applied to every patient encountered, whether it be in the emergency department, operating room, outpatient clinic, or an inpatient unit such as geriatric care, psychiatric, critical care, pediatric or obstetrics and gynecology. At this point it is very important to note that simply providing patient care and having the ability to recognize a potential forensic implication does not make one a clinical forensic nurse. The CFN not only recognizes what constitutes a medico-legal case, but knows what chain of events need to be set in motion and is able to do so. The CFN keeps current on rules and regulation for reporting, evidence collection techniques, and legal requirements of the justice system.

Sullivan says that the CFN is “forensically influenced” in all patient assessments and documentation of findings. She adds, “While the ‘forensic antennae’ are up, this nurse serves as an ideal role model for other staff in detecting inconsistencies and identifying what is potential forensic evidence in day-to-day patient-care activities.” The clinical forensic nurse examiner, Sullivan explains, frequently overlaps with the responsibilities of the CFN, although this nurse might also serve as a SANE or a medico-legal death investigator. Sullivan notes: The forensic nurse provider, if trained appropriately, may now wear the nurse examiner hat. Ideally, however, and depending on the circumstances, the forensic nurse examiner is not involved in providing patient care, unless perhaps it is in the emergency department and evidence is being collected during the course of providing treatment (removing a bullet; photographing a stab wound and then removing the clothing without cutting through the hole made by the wounding instrument). The forensic nurse examiner is called onto the scene and focuses completely on identifying, collecting, preserving, and documenting the evidence. This is a completely unbiased approach, whereas in the traditional nursing role, the caregiver is often viewed as the patient advocate. This approach would apply especially in an unexpected patient death or serious adverse patient events. It would not be appropriate for the same nurse involved in the care of the patient who expires unexpectedly to be evaluating the circumstances. Forensic nurse examiners are trained to conduct evidentiary examinations of victims of violence in and out of the hospital setting and are knowledgeable about preservation techniques when it comes to physical, medical, or trace evidence. These nurses have expertise in a specialty area such as sexual assault or death investigation and responding to crime scenes. These nurses can be qualified as fact or expert witnesses in a court of law.

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Forensic Nursing

The CFN specialists may work in a variety of health care settings, and commonly serve as scientists, educators, researchers, and consultants. Sullivan believes, “Within the hospital or clinical setting, the forensic nurse specialist has a broad range of nursing knowledge and can analyze patient-care events in a variety of specialty areas.” The CFN investigator evaluates, reviews, or otherwise investigates patient care programs, patient care delivery systems, and patient complaints, according to Sullivan. Sullivan believes that despite some surmountable current barriers to role implementation within the clinical setting, the CFN is a pivotal member of any institution’s response to medico-legal cases. She writes: The clinical forensic nurse is an essential part of the continuous efforts to improve health care delivery. The CFN role is crucial in all dimensions of patient care including the frontline, hands-on care of all patient groups in all specialty areas as well as after the fact, when the quality of care is evaluated or investigated. In addition, the CFN is in an ideal position to ensure that the rights of victims of foul play are protected within the domain of the hospital or clinical setting. As the specialty continues to evolve, roles and responsibilities are becoming more defined and essential competencies more clearly identified. However, several important questions must be confronted before the CFN can be comfortably established within the health care arena, and many of the answers will depend on the jurisdiction in which the CFN wishes to practice. There must be a standardized way of handling suspicious patient events and managing medical evidence. The pioneers of this specialty will most likely find themselves in the center of patient care events, which will benchmark future nursing practice.

1.7.2 EVERY NURSE’S HERITAGE FORENSIC NURSE

AS A

It is a conundrum because all nurses are essentially forensic nurses, yet this heritage is largely misunderstood, ignored, or not embraced by nurses. A CFN is any seasoned nurse who, through education and experience, has developed a unique set of skills encompassing medicolegal investigation, criminal justice, forensic psychology, forensic photography, or any other areas of advanced study and practice. Even though nursing’s roots in clinical forensic medicine reach back for decades, it is only recently that the discipline of forensic nursing has struggled to make a name for itself, as well as achieve formal recognition and earn validation from the health care and scientific communities. Interestingly enough, forensic scientists and pathologists first acknowledged forensic nursing; acceptance from the national nursing association would come a few years later. The American Academy of Forensic Sciences (AAFS) recognized forensic nursing as a scientific disci-

pline at its 43rd annual meeting in 1991. The field was further validated in 1992 by the formation of the IAFN. It wasn’t until 1995 when the ANA Congress of Nursing Practice granted formal recognition to the field as an official nursing specialty. Two years later, the ANA and the IAFN jointly produced the Standards and Scope of Forensic Nursing Practice to further guide practice and dispel doubts about the legitimacy of forensic nursing. Bell and Benak (2001) write, “Every nurse encounters opportunities in his or her practice to apply principles of forensics.” They point to cases of elder abuse and neglect that are seen daily in hospitals and nursing homes; victims of trauma and violence who are treated in emergency departments, operating rooms, and ICUs; and nurses working in psychiatric and correctional facilities that care for the mentally ill and the incarcerated who have experienced both roles of victim and offender. They add, “As nurses, and with diverse experience with humanity, it is possible to learn to recognize the many applications of this role . . . As a forensic clinical nurse consultant for hospitals, one can effectively intervene on behalf of clinical presentations that might include sexual assault, child/elder abuse and/or neglect, trauma, interpersonal violence and even death.” Pasqualone believes that nursing skills and medicolegal investigation abilities are complementary, parallel skill sets with immense opportunity for cross-application. She notes: My forensic training has made me a better nurse, but my nursing skills have helped me be a good investigator. As a nurse, I was taught to be a fact finder. There is no one in the world better at getting the facts than a nurse. We can ask people questions they don't realize they are answering. I have been able to develop these psychosocial skills even more with my forensic training. I am much more aware of what I am looking at; what I am smelling on someone’s clothing, on their breath or about their person; I am more aware of what they are wearing, if there is foreign debris on their clothing or under their fingernails; I am better at looking for injuries and trying to detect a pattern; so forensic science education is critical. It has developed my nursing skills so that I am better attuned to my patients. I’m not sure I would be half as good a forensic investigator if I didn’t have the nursing background.

Pasqualone likes to describe forensic nursing as a state of mind, a detective process, and an analytical way of thinking that kicks into high gear when a potential forensic case presents. “Unless you are employed in a job where you can be called a forensic nurse consultant, a sexual assault nurse examiner, or a legal nurse consultant and are doing that 40 hours a week, forensic nursing is something that is incorporated into your practice.” She explains:

Introduction to Forensic Nursing

You can be an ER nurse and suddenly a child comes in and you suspect child abuse, or an elder comes in and you suspect elder abuse. Something should click in your head and suddenly you are wearing the hat of a forensic nurse; all the things you learned about being a forensic specialist now kick in and you think about injury patterns, photo documentation and evidence collection. It may not be a hat you wear all the time, but it is a sense of knowing that exists below the surface.

Pasqualone points to home health as an example of a nursing specialty that deals with potential forensic patients. “Home health nurses would not describe themselves as forensic nurses yet they are the nurses going to what could be a primary crime scene. They are the ones who first see the environment, the people in it, and they are the first to see if there has been neglect or mistreatment in the home.” Pasqualone adds the ED or the ICU also are prime arenas in which forensic cases present. “A nurse may be caring for a patient in the ICU and discover she has been sexually assaulted; or a child is brought into the ED for a tonsillectomy, but the nurse sees bruises and isn’t sure what to make of them. That’s when forensic training kicks in. Forensic nursing isn’t necessarily one hat you put on continuously; it’s a role you fall into when the moment presents itself.” Pasqualone says that at her hospital, “nurses have not identified themselves as forensic nurses nor have they recognized what the ED nurses have done over the years because they have never really given much thought to it.” She adds: They never thought they worked in conjunction with the police. The police were always in the way; they were seen as an obstruction, so there was never anything collegial. The only occasional collegial relationship would be with the paramedics who would bring in patients from an accident scene; but then again, the paramedics weren’t educated as to what information to give the nurses and the physicians, since what they said was extremely important in reconstructing the crime. On the other hand, nurses didn’t know what to ask; maybe the paramedics had made observations at the scene and the clinicians didn’t know what to ask for, so they weren’t putting all the pieces together. Here’s a person involved in an automobile accident, and the paramedics saw something but didn’t give the right information to the nurse, and the nurse didn’t know what to ask, so perhaps she couldn’t figure out the true mechanism of injury. Luckily, some of the newer, younger doctors have begun to recognize the importance of mechanisms of injury and the fact that these telltale marks should go into the medical record. Because eventually, the case might go to court.

Pasqualone, who also teaches forensic nursing classes, adds there is hope that new generations of nurses will embrace firmly their heritage as forensic nurses:

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Some of the index of suspicion is teachable, but you acquire it over the years, too. I had five novice nurses in my last class, and they got a large dose of forensics. As fledgling nurses trying to absorb all of these principles, when they were out on the floor, they knew only enough about forensics to identify something questionable, and they knew enough to call me for consultation—and that’s good. They didn’t know what to do with the information they were looking at, but they knew to call me—something had stuck forensically. Older forensic nurses who have been around the block a time or two have seen and heard it all. They know when patients are lying, they know when the injuries aren’t matching up with the story being told, and that’s when their forensic instincts kick in. It’s something you acquire over the years, but at least with this group of young nurses, they knew when something wasn’t right. They couldn’t quite put their finger on it; while they were in the general vicinity of having something bother them, something that just didn’t make sense, they recognized it, and that’s the first step. Forensic principles have started to take root, and we just have to nurture that.

Pasqualone recalls a time when a mother brought her young son to the hospital; the boy was covered with bruises. The mother was saying that the kid was accident prone and the feelings of the nurses that day were split down the middle. A couple of the nurses believed the mother, again because child abuse just doesn’t happen in certain affluent communities, and the other nurses were upset because they believed the kid was being beaten. The nurses were at odds with each other. One nurse who felt that the mother was telling the truth became irate by the fact that we suspected her or someone in the family of child abuse. The injuries were there . . . could the kid be accident prone? Sure. Could he be so hyperactive that he bangs into things? Of course. But that’s for child protective services (CPS) to sort out. Sometimes there is no definitive reason for the injuries we see in the ER; we see the injuries but we can’t definitively say that it is or is not child abuse. If there is the least bit of suspicion, we have to report it, and let CPS make an assessment of the home and the family. What we see isn’t always the truth, so we shouldn’t push the panic button. It’s the same with elders who are black and blue with their tissue-paper skin peeling off. Is that elder abuse? Well no, not all the time. I end my elder abuse lecture with a picture of a little old lady who is black and blue from head to toe and her skin is peeling off and she’s oozing. But she’s the happiest little lady you could ever meet. She is diabetic and she says that the slightest little whack causes a boo-boo, and it’s not elder abuse. After my lecture I show a picture of this lady and I ask students, “Is this abuse?” and they are all ready to say in unison, “Yeah!” And then I say “Wrong! It’s not elder abuse.” I tell my students that you must sort it out, you have to get the whole story, and if the story doesn’t make sense, that’s when the hairs on the back of

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Forensic Nursing

your neck go up. But all of the pieces of the puzzle must fit into place. If you have one piece of the puzzle that is aggravating you and doesn’t want to fit into place, it’s better to err on the side of caution and call Protective Services. You can get all kinds of injuries in the ED and you don’t know for sure what caused them, but you call the authorities because you don’t want to be responsible for someone’s death the next time something happens.

Doing what is right by the patient, even though it might appear contrary at the time, is the advisable path to take, experts say. Pasqualone says she recalls the reactions from colleagues when she pursued not only the correct forensic protocol, but pursued an advanced education to further give her clinical actions credence: I was ridiculed for getting my two master’s degrees in forensic science. They told me I was too old, that I was being foolish, that nothing would ever come from it. I heard it all. Funny how these nurse naysayers are still working the night shift and weekends and they are miserable. In my position as clinical forensic nurse in the ED, if I collect evidence or if I ask all of the hard questions, I am modeling for others; they are watching me, they know that I am going to be fulfilling my responsibilities correctly in my role as a forensic nurse. I will not be ridiculed for my work, nor do I need to feel paranoid about what I do. That was well established about two years ago when I got called in for a case where an elderly woman had been sexually assaulted and had sustained major internal injuries. It wasn’t until they got her to the OR that they realized she had been sexually assaulted, and by that time, much of the evidence had been washed away because she had been prepped for surgery. The staff didn’t know what to do, so they called me. I very carefully took fingernail scrapings, did hair combings, and collected the clothing she had been wearing when she came into the ED. The other nurses were standing there, watching every little move I made, so I led by example. Awareness of forensic principles is growing, so forensic nurses need not feel self-conscious about their roles or their duties. They are there for a reason, and a critical one at that. It was with a great sense of pride that I collected my first piece of evidence, right after I had graduated from the University of New Haven. A stabbing victim came to the ED and I collected the T-shirt he was wearing. The cops didn’t seem to want it, but I still knew that I needed to preserve it. So I jelly-rolled it carefully, making sure not to shake any trace evidence loose, put it in its own paper bag, put my seal on it, labeled it. About a year later, the case went to court and from underneath the table, the DA pulled out a shopping bag. My face lit up, and I thought to myself, “I know that bag!” That T-shirt turned out to be one of the key pieces of evidence in that case. I remember running out of the ED door and down the driveway, screaming, screaming for the two detectives to take the T-shirt. At least they didn’t throw it out; they processed

it correctly and it was a pivotal piece of evidence. Maybe at that time my colleagues were saying, “What the heck is she doing with that T-shirt? That’s stupid,” and even the cops didn’t give it credence, but as it turns out, it was a good thing to do. So forensic nurses should never be apologetic about what they do and why they do it.

California forensic examiner Cari Caruso, RN, SANEA, recalls a time when “nursing was just nursing.” She adds: When I began to perform sexual assault examinations, we didn’t call ourselves forensic nurses. We were just nurses who performed specific tasks according to protocol. I started doing the exams in 1990 and it wasn’t until 1993 that I took a training class in sexual assault nurse examination. It wasn’t so much that I was doing everything wrong, in fact, I was doing things right. After all, I can follow directions listed on a sheet of paper; however, it was in this course that I learned about the science behind the evidentiary examination, and I relished knowing where my rape kits go and how they are processed. I liken the experience to a bracelet that you have been wearing every day for a couple of years. You never paid much attention to it until you cleaned and polished it, and then all of a sudden, it really shines and you see the beauty in the bracelet anew. That’s the way forensic nursing can be, and discovering that you work in a medicolegal environment.

In “Forensic Techniques” (2004), author Mary E. Muscari, PhD, a psychiatric-mental health nurse practitioner, pediatric nurse practitioner, and forensic nurse specialist, writes, “Nurses have long worked with forensic patients, particularly victims and perpetrators of violence. And while it is common to link the field of forensic nursing with death investigations or emergency department and correctional health settings, a significant amount of forensic nursing takes place within primary-care settings.” Muscari adds, “Primary-care nurse practitioners are in an ideal position to identify victims and perpetrators of violence and to prevent future episodes of violence. To accomplish this, nurse practitioners need to screen all patients for potential victimization or offending behavior—and document their findings appropriately.” According to the IAFN, forensic nursing encompasses the following: • • •

The application of the nursing-related sciences to public or legal proceedings The application of the forensic aspects of health care in the scientific investigation The treatment of trauma or death of victims and perpetrators of abuse, violence, criminal activity, traumatic accidents, and environmental hazards

Introduction to Forensic Nursing

Muscari (2004) writes, “Nurses share responsibility with the legal system to augment the resources available to patients with liability-related injuries, crime victims and perpetrators or suspects in police custody. This mutual responsibility represents a new perspective in the holistic approach to legal issues surrounding patient care in clinical and community-based institutions.” If U.S. nurses haven’t yet discovered their heritage, McCracken says that in her experience, Canadian nurses already have embraced this special heritage. “The nurses I meet do recognize that they are working in the trenches as forensic nurses.” McCracken works 12-hour shifts, both days and nights, helps educate ED teams, and takes the opportunity to explain why their regular work encompasses forensic imperatives: The majority of the nurses are part of Generation X and are coming from another viewpoint altogether. These new nurses definitely will grasp their forensic responsibilities. However, the Baby Boomers, the ones I trained with, are a little harder to convince that they truly are engaging in forensic practice by working in the ED. They don’t necessarily use the term “living forensics,” but they are talking about recognizing abuse and assisting people, and these are the kinds of things that we have responsibility and accountability for in our standards of care.

McCracken explains that Canadian provinces are conducting universal screening for domestic violence, a practice that is seen as being on the cutting edge, but also as an essential component of ED intervention and a natural extension of nursing practice. “It has now been mandated by our regional nursing directors that all emergency nurses must screen, universally, for domestic violence,” she explains. They view this forensic issue, domestic violence, as a health issue. It has become a standard of practice, and failing to do so is a breach of practice. After a media blitz and posters in every emergency department in the city telling patients who come into our facility that their nurse will be asking them about abuse in their life, the feedback we got was positive. Generally, the public supports our role in breaking the silence about family violence and bullying. It has also become the mandate of our provincial legislature that all agencies work together, from the courts to the shelters, from the emergency room to community and aboriginal agencies to set up a framework of action to allow all families and all individuals to live free of violence and abuse. Any time a patient comes into the ED, they are asked about their exposure to domestic violence. There has been a lot of resistance, especially coming from the older nurses

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who see it as a social issue, not a medical or health care issue, and it is none of their business. I am struggling to get them to understand that the process of asking is intervention, so I’ve planted a seed in their minds at the very least. I have tried to explain to them that this screening is now looked upon not as an option, but as a standard of practice that must be met just as you do vital signs. Our nursing managers are realizing the importance of the screening by nurses and they are on board, but we still need to get nurses to understand that the very act of asking is important—whether you disclose or not is not the issue. You have planted the seed that being beaten by an intimate partner is wrong.

McCracken says she has given much thought to the idea of expanding her nursing role in the field of domestic violence: Our city is a leader in the country in dealing with this issue, with its domestic violence conflict units, court system, and multiagency support groups. It is looking to house all these resources in one big center, something like the Family Justice Concept in San Diego. What they are missing on their team is a nurse who is part of the intake team assessing the victim for injuries, and photographing and documenting those injuries, and then linking the victim to the support agencies. I would like to be that nurse, and I am putting together a job proposal.

Forensic nurses in clinical settings recognize the forensic implications of every case that presents to the health care facility. They serve as the bridge between health care and the medico-legal community. Forensic nurses recognize forensic implications in even the most routine patient care situations and in health care worker interactions, as well as suspicious injuries, adverse events, and unexpected death. The forensic nurse is involved in all aspects of patient care, along the entire patient care continuum, from admission (traumatic or not), in triage in the ER, admission for a violent event, chronic disease, ICU, acute care, subacute care, long-term care and hospice, to homehealth care. Sullivan (2002) states: The clinical forensic nurse is an essential part of any hospital team with the responsibility to evaluate and perform the root cause analyses (RCAs) of adverse patient events. Adverse patient events range from those causing minimal concern, to extremely serious action, but the vast majority of these are not criminal in nature. Regardless, the precise identification, collection, and management of facts, data, and medical evidence are critical, criminal or not. It is the duty of every health care provider to ensure a high level of quality patient care and accurate delivery of such services. This means all health care providers must

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Forensic Nursing

have some level of awareness of what constitutes medicolegal significance. In addition, our patients deserve a safe environment in which to receive health care and health care providers deserve a safe place to practice.

In the clinical arena, forensic issues range from trauma and wound pattern evaluation to proper evidence collection and management and even to the evaluation of the level of care provided and timeliness of treatment. The role of the CFN is critical in each area of patient care delivery in that the nurse is most often the first to see the patient, whether in triage, as first responder in a code arrest, before the patient sees the primary care provider in a clinic, or before the elderly patient is formally admitted into the nursing home. Recognition of overt and subclinical abuse and neglect, as well as situations in which artificial means are used to create illnesses is often obscured by the mindset of the health care provider who is focused on natural illnesses (Anderson, 1998). The astute forensic nurse practicing in a clinical setting is able to maintain a professional balance between nursing assessments of natural illness while considering all possibilities, no matter how distasteful. Consideration of all angles and maintenance of a heightened awareness does not mean the clinical forensic nurse focuses only on the next investigation, but instead, a more thorough assessment of any given patient situation. (Sullivan, 2002)

Health care professionals traditionally have been trained to identify natural causes of injury and disease; however, overt as well as covert situations and manifestations relating to violence and neglect are in the purview of the forensic nurse.

1.7.3 CLINICAL FORENSIC NURSING PRACTICE Lynch (1995) writes, “In a comprehensive approach to the unmet needs of forensic victims who survive violent crimes and traumatic injuries, enhanced involvement in assisting the living is being explored through new roles for the emerging clinical forensic medical and nursing specialist.” Previously, a patient had to die under extraordinary circumstances to be examined by an expert in forensic issues. New forensic specialists will become the designated clinicians who will evaluate and assess surviving victims of rape, drug and alcohol addiction, domestic violence (including abuse of spouse, children, elderly), assaults, automobile and pedestrian accidents, suicide attempts, occupation-related injuries, incest, medical malpractice and the injuries sustained therefrom, and food and drug tampering. Their injuries are the concern of society as a whole and require a combination of social systems interfacing with health care and the law

to provide solutions. Contemporary roles require new responsibilities, including the determination of the circumstances surrounding trauma and the mechanism of injury, the identification of human rights violations (e.g., physical torture as well as neglect while in custody, during institutionalized or protective care, or in private homes), and determination of unsafe conditions and products (e.g., workplace hazards, injuries from toys, exposure to toxins, vehicular accidents). Any patient admitted to the hospital with liabilityrelated traumatic injuries is considered a clinical forensic patient. The case must be reported to a legal agency to ensure that proper investigation and follow-up action will ensue. The hospital staff most often comes in contact with police, victims, and perpetrators of violence and crime in the ED. Protection of the patient’s rights remains the common goal of police officers and trauma nurses. Every hospital, regardless of its size and location, must eventually address problems of conflict with law enforcement agencies. Most often, these conflicts concern patients in legal custody and perpetrators of crime, as well as the confidentiality of victims’ medical records. Policies that increase mutual understanding, define responsibilities, and promote coordination contribute to multidisciplinary, multiagency cooperation. The nurse’s role as a clinical investigator provides a vital liaison between the investigative process and courts of law. Although there are numerous subspecialties of forensic nursing, Mary K. Sullivan, RNC, CARN, MSN, BSN, forensic nurse examiner team coordinator for the U.S. Department of Veterans Affairs in Phoenix, asserts that one such forensic niche that has experienced difficulty in achieving traction is clinical forensic nursing, which she characterizes as “under-represented and difficult to implement . . . within the general hospital setting.” She writes, “Nurses who possess forensic expertise have not been formally recognized or utilized in their hospital or clinical settings. In my opinion, using a clinical forensic nurse examiner (CFNE) would be a reasonable approach for several problems that health care facilities face today. Such a role requires nurses with a broad range of forensic knowledge and skills.” Sullivan enumerates the responsibilities of a CFNE. One important duty, she says, is ensuring that “trauma patients receive systematic assessments and that the findings are precisely documented. Identification, collection, and preservation of evidence in suspicious patient events or unexpected patient death are equally important functions.” The CFNE would also function as a staff educator, raising awareness of forensic protocols as well for the potential for forensic cases to present in everyday patient care situations. “An extant member of the hospital staff who can work handin-hand with law enforcement agencies is vital to protect

Introduction to Forensic Nursing

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victims of foul play when they are at their most vulnerable,” Sullivan writes. Lynch (1997) says that CFN specialists are properly trained to identify, save, and preserve key pieces of physical evidence that might have been ordinarily destroyed. Lynch writes, “Complaints by law enforcement officers concerning nurses and EMTs refer to their constant struggle to save evidence from the well-meaning hands of uninformed emergency department practitioners and first responders.” She adds, “Among the most important requests by police officers is for health care providers to preserve clothing removed from injured people in one piece; for example, cutting through a bullet hole may destroy its potential as evidence.” Lynch says a forensic clinical nurse specialist can resolve these issues in the ED. Sullivan advocates for the 24/7 presence of a CFNE in every health care institution, explaining that “these nurses would continue to meet whatever their usual position responsibilities might be, but be on call for forensic consultation when other health care staff perceived a need.” This might not be a realistic plan for most health care facilities to implement, so Sullivan suggests that one CFNE could be scheduled 24/7 in the emergency department and one CFNE could cover the rest of the facility, similar to the way nurses function on code teams. “Forensic nurses as an integral part of the hospital’s health care team would seem to be more accepted by peers than someone ‘coming in from the outside,’” Sullivan notes, adding, “although this dual role has inherent challenges, no one knows more about the inner workings of a hospital and what it takes to deliver quality patient care than a nurse.” Lynch (1995) maintains that implementation of the role of CFN would provide “a uniquely skilled and qualified forensic professional” whose responsibilities would be to develop the appropriate forensic protocols in compliance with accreditation standards; triage patients at risk for forensic injuries; report to proper legal agencies; document, collect, and preserve evidence; secure evidence and maintain the chain of custody; and serve as liaison between the health care institution, law enforcement agencies, and the medical examiner or coroner and make referrals when medical treatment or crisis intervention is required.

tic violence admitted to 397 emergency departments in California. Researchers discovered that only 5 percent of adult victims of domestic violence were identified, due to time constraints, lack of training, and reluctance by health care professionals and patients to discuss domestic violence. Only 59 EDs surveyed had specific forensic policies, and only eight were adequately addressing identification, treatment, and intervention. Although response rate indicated that health care professionals were enthusiastic about helping these victims, few had developed programs to do so. Lynch (1995) writes, “California is not alone in facing violence and its associated trauma. If time constraints interfere with the ideal clinical intervention in such cases, the presence of forensic specialists in nursing can ease the workload of the physician and better meet the needs of the victim of domestic violence, the criminal justice system, and other medico-legal agencies.” If the American Trauma Society is correct in its report that victims of domestic violence present to the hospital ED six times more often than members of the general population, the presence of CFNs as uniquely skilled and qualified forensic professionals could ensure health care facilities meet their responsibility of addressing interpersonal violence. Lynch (1995) envisions the nurse’s responsibilities as developing the appropriate forensic protocols in compliance with accreditation standards; triaging patients at risk for forensic injuries; reporting to proper legal agencies; documenting, collecting, and preserving evidence; securing evidence and maintaining the chain of custody; and serving as a liaison between all relevant parties in the medico-legal community—the health care institution, law enforcement agencies, and the medical examiner or coroner. Muscari (2004) advocates:

1.7.4 THE ROLE OF SCREENING FORENSIC NURSING

1.7.4.1 Screening for Interpersonal Violence

IN

CLINICAL

Forensic nurses serve a critical function by screening for potential forensic cases as they enter the health care system, whether it is through the ER, the ICU, the OR, or other inpatient or outpatient hospital departments. Lynch (1995) cites a 1992 study conducted by the Family Violence Prevention Fund in San Francisco and the San Francisco Injury Center for Research and Prevention that evaluated the circumstances of victims of domes-

Screen all patients for signs of victimization and violent offending, and be sure to screen across patient populations. Thus, pediatric nurse practitioners (NPs) should screen patients for partner violence, adult NPs should screen patients for child and elder abuse, and so on. All NPs should screen for animal cruelty, which has been associated with numerous forms of violence, as well as the presence of weapons in the household.

Screening for interpersonal violence (IPV) or intimate partner violence is within the realm of the forensic nurse’s responsibilities as a frontline health care professional. Muscari (2004) writes, “IPV affects women and men in both heterosexual and same-sex relationships, and it can occur in teens through older adults.” She points to a study of 149 abused women presenting to the justice system for protection orders or to file assault charges showing that only 24 percent of the 126 (86 percent) who had sought

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health care in the previous year had been assessed for IPV (Willson et al., 2001). Abuse of men has received little attention, but does exist, and the rate of domestic violence in the gay community is similar to that in the heterosexual community (Dalsheimer, 1998). Muscari writes, “Between 8 percent and 53 percent of adolescents report a history of being physically assaulted by an intimate partner, and unlike abuse in adult relationships, studies find similar rates of victimization among boys and girls.” The American Medical Association (AMA) and other organizations recommend screening for IPV, and several clinically useful, valid screening tools are available, including the Partner Violence Screen, the HITS (Hurt, Insulted, Threatened, Screamed), and the WAST (Women Abuse Screening Tool). Positive results from these tools should be followed by use of the Danger Assessment and the HARASS (Harassment in Abusive Relationships: A Self-Report Scale) questionnaires to assess for domestic homicide risk. Risk factors for this include the victim leaving for another partner, the perpetrator’s use of a gun, stalking, forced sex, and abuse during pregnancy (Campbell et al., 2003; Sheridan, 2003). 1.7.4.2 Screening for Child Abuse Muscari (2004) writes, “The behavioral and physical signs of child abuse and neglect have been well documented. Nurse practitioners should become familiar with them.” The U.S. Department of Justice’s Portable Guides to Investigating Child Abuse is available online at http://www .ncjrs.org/html/ojjdp/portable_guides/abuse_02/contents .html. According to Muscari, risk factors for child abuse include prematurity and low birth weight; being perceived as “different” or “unusual”; congenital anomalies; disabilities or chronic illness; and living in families with poverty, substance abuse, unemployment, high crime, or violence. She writes, “Histories tend to reveal clues such as multiple admissions or emergency department visits, ‘doctor shopping,’ and domestic violence. Parents may be reluctant to provide an account of the injury, may give conflicting histories, or may provide a history inconsistent with the injury (a 4-year-old with a bilateral fractured mandible who ‘fell off a five-story fire escape’).” 1.7.4.3 Screening for Elder Abuse According to the National Center on Elder Abuse, any knowing, intentional, or negligent act that causes harm or serious risk of harm to a vulnerable adult constitutes elder abuse. Laws vary by state, but abuse can be categorized as physical, emotional, sexual, exploitative, neglect or abandonment. Risk factors for abuse are social isolation, mental impairment, a history of domestic violence, and, in some situations, simply living with someone else, such

Forensic Nursing

as a friend or caregiver. “All older adults should be screened for abuse, despite the paucity of appropriate screening tools,” according to Muscari (2004). Nurse practitioners can use the Elder Assessment Instrument (EAI), a 41-item scale that reviews symptoms and subjective complaints of elder abuse, neglect, exploitation, and abandonment. Muscari advises nurses to “refer patients if there is any evidence of mistreatment without sufficient clinical explanation; the patient voices a subjective complaint of mistreatment; or you believe there is high risk for or probable elder abuse.” 1.7.4.4 Screening for Rape Muscari (2004) explains, “Nurse practitioners should also assess patients for violence outside the home, including the workplace, school and community. Violent acts can also occur in nursing homes and residential facilities, and assault and rape can take place anywhere. Many rapes go unreported—for reasons such as humiliation, shame, fear and denial—yet only a small percentage of health care providers routinely screen their patients for physical or sexual assault.” When screening patients for sexual assault, Muscari advises that it is best not to use the word rape, as patients might not define rape in the same manner. “Instead, ask patients if anyone has ever forced them to have sex or to perform a sexual act. Screening during primary care visits is critical because some victims develop a silent reaction to rape, never telling anyone about the incident. These patients may exhibit signs of distress during the interview, such as poor self-esteem, lack of self-confidence, paranoia, dissociation, prolonged periods of silence and stuttering.” 1.7.4.5 Screening for Offenders “Violence is any assault that causes or intends to cause serious harm to other people. Health care providers should know that stress does not directly cause violence, but the probability of aggression in response to stress increases when certain conditions, such as lower socioeconomic status, early socialization to violence and lack of social integration, are present,” Muscari (2004) writes. She says that substance abuse and schizophrenia have also been associated with aggression, and the most predictable risk factor for violence is previous commission of a violent act. Regarding batterers, Muscari says, “No consistent psychiatric disorders have been noted among batterers, but abusive men share similar characteristics, such as low selfesteem, rigid sex-role stereotypes, depression, an intense need for power and control, a tendency to minimize the extent of their violence, a tendency to blame others for their behavior, violence in their family of origin, and substance abuse.” Studies have shown that women batterers typically are young, anxious, emotionally excitable, worrisome,

Introduction to Forensic Nursing

prone to substance abuse, tough-minded, uncaring, insensitive to others, and antisocial. They also have a history of family violence. Muscari notes that several researchers have recommended using the funneling technique to assess battering behavior, a technique that moves from general, open-ended questions to specific, direct questions that assess violent behavior. “Batterers tend to minimize their behavior, so questions may elicit euphemisms such as ‘had a bad day,’ ‘lost my temper,’ or ‘self-defense’ to refer to their own violent behavior,” Muscari says. Child abusers might be attempting to cope with personal attributes such as detection of immaturity, adolescent parenting, lack of parenting skills, unrealistic expectations of the child, unmet needs, isolation, poor impulse control, life crises, physical or mental health problems, and substance abuse, Muscari observes. “Parental demeanor during the interview can be quite revealing . . . Signs that a woman may be reaching her coping limit include claims that the baby is too difficult or heavy, thoughts of harming herself, or bizarre thoughts about the baby. Thoughts of self-harm or harm toward the baby require immediate attention.” Elder abusers might be persons out for financial or personal gain, or caregivers who have difficulty coping with the demands of caring for an elderly parent. Finally, individuals who commit sexual violence might be looking for sexual expression of power and anger, motivated by retaliatory and compensatory intent, Muscari says. Health care providers are challenged by the need to identify potential offenders based on the evidence of injury or information collected through a patient interview and history. “Offenders are not likely to voluntarily discuss their violent acts. Thus, alternate interviewing techniques are necessary,” Muscari says. She explains that one method, known as the forensic genogram, provides information about the transmission of family patterns (including violence) that assist health care providers and the court in understanding offenders. Individual and family patterns of victimization, substance abuse, suicide attempts, and criminal activity can be mapped. Muscari writes, “Since offenders often present with extreme behaviors, genogram patterns are often profound. Understanding family influences ultimately assists in understanding the events that may have led to the offender’s behavior. The genogram often reveals an upbringing of abuse, ineffective communication patterns and substance use. Average families have one or two members with maladaptive functioning; forensic families possess numerous dysfunctions.” Lynch (1997) says that health care providers have a duty to not only screen patients for signs of trauma of medico-legal significance, but to be familiar with their state’s reporting requirements. She writes, “State reporting statutes specifically mandate that health care professionals who have cause to believe that an individual is being abused or neglected must report that suspicion to the

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proper authorities.” States vary as to what must be reported, who should receive the report, and what degree of protection from liability the law offers to the person making the report. In general, Lynch says, cases that require reporting by health care providers include injuries caused by a lethal weapon, certain kinds of motor vehicle trauma, self-inflicted injuries, drug overdoses and poisoning, suspected criminal abortions, animal bites, child and elder abuse, sexual assault, individuals determined to be “dead-on-arrival,” and individuals who have been treated in a hospital for wounds that could have been inflicted as a result of violence.

REFERENCES Anderson, W. R. Medicolegal implications in clinical patient evaluation and treatment. In Forensic Science in Clinical Medicine: A Case Study Approach (pp. 223–234). Philadelphia: Lippincott-Raven. 1998. Bell, K., & Benak, L. D. Forensic nursing: The fastest growing discipline of nursing for the 21st century. Available online at: www.iafn.org. 2001. Campbell, J., Webster, D., Koziol-McLain, J., & Block, C. Risk factors for femicide in abusive relationships: Results from a multi-site case control study. Am J Public Health. 93, 7, 1089–1092, 2003. Dalsheimer, J. Battered men: A silent epidemic. Top Emerg Med. 20, 4, 52–59, 1998. Easen, P., & Wilcockson, J. Intuition and rational decision making in professional thinking: A false dichotomy? J Adv Nurs. 24, 4, 667–673, 1996. Eckert, W., et. al. Clinical forensic medicine. Amer J Forensic Med Path. 7, 3, 101, 1986. Garner, B. Black’s Law Dictionary (Second Pocket Edition). St. Paul, MN: West Group. 2001. Lynch, V. A. Clinical forensic nursing: A new perspective in the management of crime victims from trauma to trial. Critical Care Nursing Clinics of North America. 7, 3, 489–507, 1995. Lynch, V. A. Clinical forensic nursing: A new perspective in trauma. Collins: Bearhawk Consulting Group. 1997. McCracken, L. M. Living forensics: A natural evolution in emergency care. Accident and Emergency Nursing. 7, 211–216, 1999. Muscari, M. E. Forensic techniques. Advance for Nurses Online. Sept. 2004. Paul, R. W., & Heaslip, P. Critical thinking and intuitive nursing practice. J Adv Nurs. 22, 1, 44–47, 1995. Sheridan, D. Forensic identification and documentation of patients experiencing intimate partner violence. Family and Community Violence. 5, 1, 113–141, 2003. Smock, W. S. Forensic emergency medicine. Presentation at Forensic Focus conference, Scottsdale, AZ. June 2003. Smock, W. S., Nichols, G. R., & Fuller, P. M. Development and implementation of the first clinical forensic medicine training program. J Forensic Sci. 38, 4, 835–839, 1993. Sullivan, M. K. Clinical forensic nursing: A higher standard of care. Forensic Nurse, 1, 1, 4, 2002. Sullivan, M. K. Opportunities and challenges in forensic nursing. In V. A. Lynch, Ed., Forensic Nursing in the Hospital Setting. In press, 2005.

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Willson, P., Cesario, S., Fredland, N., & Walsh, T. Primary health care providers’ lost opportunity to help abused women. J Am Acad Nurse Pract. 13, 12, 565–570, 2001. Winfrey, M. E., & Smith, A. R. The suspiciousness factor: Critical care nursing and forensics. Crit Care Nurs Q. 22, 1, 1–7, 1999.

RECOMMENDED READINGS Barber, J. Frontiers and challenges in critical care: Foreword. Crit Care Nurs Q. 14, 3, 1991. Brenner, P., Tanner, C., & Chesla, C. From beginner to expert: Gaining a differentiated clinical world in critical care nursing. Adv Nurs Sci. 14, 3, 13–28, 1992. Burgess, A. W. Violence Through a Forensic Lens (Second Edition). King of Prussia, PA: Nursing Spectrum Publishers. 2002. Butt, J. Sudden Death and Police Investigations (Second Edition). Calgary. 1993. Courson, S. The investigative specialty of forensic nursing. Pennsylvania State Nurses Association Career Center. Available online at http://www.psna.org/Career/forensic.htm. Duval, J. Role of the forensic nursing specialist in an urban trauma center. In Proceedings of the 47th Annual Meeting of the American Academy of Forensic Sciences. Seattle. 1995. Eyler, A., & Cohen, M. Case studies in partner violence. Am Fam Physician. 60, 2568–2576, 1999. Hamberger, L., & Lahti, J. The family peace project: A model for training health care professionals to identify, treat and prevent partner violence. J Aggression. 1, 55–81, 1997.

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International Association of Forensic Nurses. Available online at http://www.forensicnurse.org/about/default.html. Kent-Wilkinson, A. Forensic family genogram: An assessment and intervention tool. J Psychoso Nurs and Ment Health Serv. 37, 9, 52–56, 1999. Lynch, V. A. Forensic nursing in the emergency department: A new role for the 1990s. Crit Care Nurs Q. 14, 3, 69–86, 1991. Lynch, V. A. Forensic aspects of health care: New roles, new responsibilities. J Psychosoc Nurs and Ment Health Serv. 31, 11, 5–6, 1993. MacNamara, H. Living forensics (seminar brochure). Office of the Medical Examiner, Ulster County, New York. 1988. Marsh, T. A nurse’s guide to sleuthing. RN. 41, 8, 48–50, 1978. McCracken, L. A link in the chain in the medico-legal process of evidence. NENA Outlook Magazine. 21, 1997. McCracken, L. Living forensics: A natural evolution in emergency care. Accident and Emerg Nurs J. 7, 4, 211–216, 1999. McCracken, L. The forensic ABC’s of trauma care. Canadian Nurse. 97, 3, 30–33, 2001. Mittleman, R., Goldberg, H., and Waksman, D. Preserving evidence in the emergency department. AJN. 83, 12, 1652–1656, 1983. Sanders, C. The world of forensic nursing (Course No. 241). Available online at http://www.OnlineCE.net. Smock, W., Ross, C., & Hamilton, F. Clinical forensic medicine: How ED physicians can help with the sleuthing. American Health Consultants. 5, 1, 1–8, 1994. Stea, J. Behavioral health force protection: Optimizing injury prevention by identifying shared risk factors for suicide, unintentional injury, and violence. Mil Med. 167, 11, 944–950, 2002. Taylor, W. Sexual assault: Identification, treatment and referral in the emergency department. Top Emerg Med. 20, 4, 4–11, 1998.

Nursing as Part of the 2 Forensic Nursing Process CONTENTS 2.1 The Nursing Process................................................................................................................................................ 23 2.2 The Forensic Nursing Scope of Practice ................................................................................................................ 26 2.3 The Scientific Method ............................................................................................................................................. 26 2.4 Forensic Nursing Science: A Logical Next Step? .................................................................................................. 27 References ......................................................................................................................................................................... 31

2.1 THE NURSING PROCESS At its core, nursing is the symbiotic relationship of art and science applied within the context of interpersonal relationships for the purpose of promoting wellness, preventing illness, and restoring health. The American Nurses Association (ANA) defines nursing as the “diagnosis and treatment of human responses to actual or potential health problems.” The nursing process was established in 1973 through the formalization of the ANA’s standards of practice, and it functions as a nurse’s own “scientific method” for patient-care delivery. The nursing process is an elemental framework on which basic tenets of nursing rest. It is a systematic problem-solving approach used to identify, prevent, and treat actual or potential health problems and promote wellness. Elements of the nursing process are the essential building blocks with which nurses of all specialties—including forensic nursing—build their respective practices. Forensic nurses base their specialized practice on these core values, adapting them to fit the unique aspects of their medico-legal work. It should be of some comfort, both to the uninitiated forensic nurse and to the colleague in the greater forensic science community, that the nursing process is predicated on an orderly, scientific, medicolegal approach. Like forensic nursing itself, the nursing process is dynamic, client oriented, goal directed, universally applicable, and most important, problem and solution oriented. Many forensic cases present first in the emergency room, a place where the nursing process is most readily put to the test. Patricia Ann Bemis, RN, CEN, author of Clinical Practice Guide of Emergency Care: The Ultimate Core Curriculum, says that the structure of the nursing process lends organization to a tumultuous health care

environment in which emphasis on a team approach is critical. Bemis (2003) writes: Organized chaos describes the emergency room. The nine steps of the emergency care process . . . are the organized part of the chaos. By using the same care process, all members of the emergency team can anticipate the care of the other and interrelate as a team. A team approach leads to stronger professional practices and improved patient outcomes. During a true emergency, it may be necessary to perform the steps simultaneously or out of sequence. When the care process is known and the same for all team members, the ability to adapt to change during a true emergency is easy.

Bemis explains that each team member must do the following: • • • • • • • • •

Perform a quick ABC (airway, breathing, circulation) assessment. Identify the patient. Use the patient’s words for the chief complaint. Ask relevant questions to develop a history of the present illness. Develop nursing diagnoses related to the nature of the emergency. Plan by anticipating the medical care. Identify and perform initial assessments and interventions. Identify and perform ongoing evaluations and interventions. Provide discharge instructions.

Particularly in the ER setting, a nurse must quickly evaluate the patient with the AVPU mnemonic: A for alert signifies the patient is alert, awake, responsive to voice, 23

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and oriented to person, time, and place. V for verbal signifies the patient responds to voice, but is not fully oriented to person, time, or place. P for pain signifies the patient does not respond to voice, but does respond to painful stimulus such as a squeeze to the hand. U for unresponsive signifies the patient does not respond to painful stimulus. The first step in the nursing process is assessment, steeped in data collection, or a systematic gathering of information about the patient that incorporates observation, interview, consultation, and examination. The patient is the primary source of both objective and subjective information, and secondary sources include the patient chart, family members, and health care colleagues. Subjective data—commonly called symptoms—is the information the patient or the caretaker tells the nurse during the nursing assessment. Objective data—commonly called signs—is information collected by using the senses, collecting information that can be seen (observation), felt (palpation), heard (auscultation or percussion), or smelled. A patient’s health history consists of biographical data, chief complaint, present illness and health status, past history, current health information, and family history. According to Bemis, The patient’s identity, chief complaint, and history of present illness are developed by interview. The standard questions are who, what, when, where, why, how, and how much. “Who” identifies the patient by demographics, age, sex, and lifestyle. “What” develops the chief complaint that prompted the patient to seek medical advice. “When” determines the onset of the symptom. “Where” identifies the body system or part that is involved and any associated symptoms. “Why” identifies precipitating factors or events. “How” describes how the symptom affects normal function and describes the severity of the affect. The chief complaint is a direct quote, from the patient or other, stating the main symptom that prompted the patient to seek medical attention. A symptom is a change from normal body function, sensation, or appearance. A chief complaint is usually three words or less and not necessarily the first words of the patient. Some investigation may be needed to determine the symptom that prompted the patient to come to the ER. When the patient, or other, gives a lengthy monologue, a part of the whole is quoted.

Bemis advises nurses to use direct quotes to document the chief complaint, as well as to attribute the source of the quote, such as “the patient states . . .” or “John Smith, the husband, states. . . .” When taking the history of the present illness or injury, Bemis says nurses must ask themselves a multitude of probative questions, such as: • •

If a weapon was involved, where is the weapon? When did the symptoms begin?

• •

• •

If the symptoms are no longer active, how long did they last? If the symptoms were intermittent, how long did each episode last and how frequent were they? Where are the physical injuries and what body system is involved? Are any other symptoms associated with the chief complaint, such as drug or alcohol intoxication, nausea, vomiting, headache, sweating, or irregular or fast heartbeat?

With answers to these questions, nurses then should reconsider the nature of the emergency and consider whether a clinical presentation is masking for another medical condition such as: • • • • •

Overdose and poisoning for an overdose Carbon monoxide inhalation for carbon monoxide poisoning Stabbing, gunshot, and penetrating injury for injuries from a weapon Laceration for a laceration Hemorrhage for a laceration with hemorrhage

Bemis says nurses must then ask the hard questions, such as: •

• •

• • • • •

•

Did an emotional crisis, such as a relationship crisis, disagreement, confrontation, or situational conflict, precede the symptoms? Is unlawful activity suspected? Was law enforcement at the scene? Which agency might have been present? (This question must be considered, as medical personnel are obligated to notify law enforcement if unlawful activity is suspected.) Has any treatment been initiated? Has it helped? Has the patient had similar problems before? When? What was the diagnosis and treatment? Does the patient have any pertinent past history? Does the patient take any routine medications? If so, what is the name, dosage, route, and frequency of the medication and when was the last dose taken? Does the patient have allergies to drugs or foods? What was the reaction?

In the nursing assessment, the patient’s biophysical and psychosocial status is observed. Biophysical components are • •

Integument Head and neck

Forensic Nursing as Part of the Nursing Process

• • • • • •

Respiratory Cardiovascular Musculoskeletal Neurological Genito-urinary Reproductive

The psychosocial components are • • • •

Psychological Spiritual Social Developmental

Lynch (1997) writes, “In performing a forensic assessment, the forensic nurse specialist (as a clinical investigator or emergency clinician) is required to maintain an objective evaluation of the account provided in incidents of abuse.” She outlines this list of factors that might assist nurses in confirming a suspicion of abuse: • • •

• • •

• •

Multiple hematomas or scars in various stages of healing Concurrent injuries or evidence of neglect History of previous hospitalization for “accidental” trauma that is not explained fully or substantiated by the evidence Delay in the patient seeking medical attention and treatment Injuries appearing to be older than the alleged time or day of the accident An account of the injury that is incompatible with the age or ability of the patient, as in the instance of pediatric patients The patient appears to be excessively withdrawn or submissive Pattern injuries are indicative of suspicious or inflicted—not accidental—trauma

The second step in the nursing process is the nursing diagnosis. According to Carroll-Johnson and Paquette (1994), nursing diagnosis is defined as “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” The nursing diagnostic statement is comprised of three elements: 1. The nursing diagnosis statement describes alterations in the patient’s health status and ability to function. 2. The etiologies are those factors contributing to the existence or maintenance of the patient’s

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health problem. These factors can be pathophysiological, psychosocial, situational, developmental, cultural, and environmental. 3. The defining characteristics are a cluster of subjective and objective signs and symptoms that represent a nursing diagnosis. The defining characteristics, gathered during the assessment phase, provide evidence that a health problem exists. The symptoms (subjective data) are changes that the patient feels and expresses verbally to the nurse. The signs (objective data) are observable changes in the patient’s health status. Nurses are advised to use the phrase “as evidenced by” (AEB) to connect the etiology and defining characteristic statement. The nursing diagnoses are arranged and presented in the order of priority according to urgency and importance. The third step in the nursing process is planning, which documents the characteristics of patient outcomes and goals, such as being • • • •

Patient-centered Specific and measurable Realistic for the individual patient Of a limited time frame, with a target date and time for achievement

The fourth step in the nursing process is implementation of nursing intervention, which is defined as “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes. Nursing interventions include both direct and indirect care; nurse-initiated, physician-initiated, and other provider-initiated treatments” (McCloskey & Bulechek, 2000). Nursing activities are defined as “the specific behaviors or actions that nurses do to implement an intervention and which assist patients/clients to move toward a desired outcome” (McCloskey & Bulechek, 2000). When selecting an intervention, nurses must consider the following factors: • • • • •

Characteristics of the nursing diagnosis Research base for the intervention Feasibility of performing the intervention Acceptability to the patient Capability of the nurse

The fifth step in the nursing process is evaluation. The patient care plan is reviewed to determine if the patient’s needs are being met and whether or not the stated goals are being achieved. The care plan can then be revised, continued, or discontinued based on its effectiveness.

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In the ER environment, Bemis says initial assessments and interventions include the following: •

• • • • •

• •

Considering where the patient is placed within the ER, as the goal is to provide a safe, harmless, and nonhostile environment. Communicating in short, concise statements while establishing rapport and trust. Encouraging the patient to verbalize. Getting vital signs. Performing a focused physical assessment of any areas of injury. Informing the patient, family, and caregivers of the usual plan of care and the expected overall time in the ER. Providing the patient with a device to reach someone for assistance and explaining how to use it. Establishing a set of rules for movement about the department and asking the patient to agree with the rules.

Ongoing evaluations and interventions include the following: • • • •

•

•

•

• •

Monitoring temperature, heart rate, blood pressure, and effectiveness of breathing. Monitoring therapy closely for the patient’s therapeutic response. Informing the physician of adverse changes noted during ongoing evaluation. Documenting that the physician was notified of the adverse change and what orders, if any, were received. Monitoring closely for the development of adverse reactions to therapy and performing interventions to relieve the adverse reaction; asking the physician for a remedy. Keeping the patient, family, and caregivers well informed of the plan of care and the remaining time anticipated before disposition. Monitoring the patient’s laboratory and X-ray results and notifying the physician of critical abnormalities; remedy abnormalities as ordered. Notifying the physician when all diagnostic results are available for review. Asking for establishment of a medical diagnosis and disposition.

2.2 THE FORENSIC NURSING SCOPE OF PRACTICE In each step of the nursing process, forensic nurses plug into this formula the specific bits of data pertinent to a forensic case. The steps along this path are the same in

forensic nursing as they are in any other nursing specialty, where the forensic nurse provides continuity of individualized care at the same time as preventing omissions and duplications in care. Throughout the nursing process, forensic nurses employ critical thinking skills that encompass: • • • • • • • •

Reasoning Conceptualization Reflection Autonomous thinking Impartial decision making Problem solving Intuition Inductive and deductive reasoning

Says clinical nurse specialist Janet Barber, MSN, RN: There are many people raising the question about where forensic nursing fits within the scope of nursing. However, I think that since the American Academy of Nursing has inducted nurses into the academy based on their work in forensic nursing, and the ANA has endorsed the forensic nursing scope and standards of practice, all of these things point to the fact that the barriers are coming down and the wider field of nursing science is beginning to say yes, forensic nursing does fit, yes, it is a nursing role and responsibility. They are saying, “It is a specialty with which we are going to have to reckon.” I think many are still trying to figure out how forensic nursing logically fits into the overall nursing framework and how it interfaces with other disciplines, but I don’t think there is any question anymore about whether or not it fits. I would say that yes, there is increasing evidence in the nursing literature that the application of the nursing process is being made to various steps in forensic nursing. I think that whatever they are doing, forensic nurses always perform the various steps in the nursing process, conducting thorough data collection, assessments, planning, interventions, and evaluations. They consult each step of the nursing process and ask themselves, “Have I considered all of these elements?” and “How do they fit into forensic practice?”

2.3 THE SCIENTIFIC METHOD What’s more, both the nursing process, and especially the forensic nursing scope of practice, embrace the use of the scientific method, especially in the medico-legal arena. It is the process by which scientists, collectively and over time, endeavor to construct an accurate, reliable, consistent, and nonarbitrary representation of the world. In the recognition of the influence that cultural and societal beliefs have on an individual’s perceptions, the use of standard procedures and criteria minimizes those influences and eradicates bias when a theory is being developed.

Forensic Nursing as Part of the Nursing Process

According to Bright (1952), the four steps of the scientific method are: 1. Observation and description of a phenomenon 2. Formulation of a hypothesis to explain the phenomenon 3. Use of the hypothesis to predict the existence of other phenomena, or to predict quantitatively the results of new observations 4. Performance of experimental tests of the predictions by several independent experimenters and properly performed experiments If the experiments bear out the hypothesis it might come to be regarded as a theory or law of nature; however, if the experiments do not bear out the hypothesis, it must be rejected or modified. Key to the scientific method, experts say, is the predictive power of the hypothesis or theory, as tested by the experiment (Barrow, 1991). It is often said in science that theories can never be proved, only disproved, as there is always the possibility that a new observation will conflict with a long-standing theory. The scientific method requires that a hypothesis be ruled out or modified if its predictions are clearly and repeatedly incompatible with experimental tests. Further, its predictions must agree with experimental results if it is a valid description of nature. Experiments can test the theory directly or can test for consequences derived from the theory using mathematics and logic.

2.4 FORENSIC NURSING SCIENCE: A LOGICAL NEXT STEP? Virginia A. Lynch, MSN, RN, is among a growing number of leaders in forensic nursing thought who embrace the relatively new term of forensic nursing science as a way to elevate this specialty of nursing practice and to celebrate its roots in science. Lynch says: To establish the foundation upon which forensic nursing is designed, it is necessary to examine the history of clinical forensic medicine, or living forensics, as it is sometimes called. This is a new field of inquiry brought to the attention of clinical nursing through an integrative practice model that unites the disciplines of nursing science, forensic science, and criminal justice in the common goal of protection of the victim’s legal, civil, and human rights. As greater numbers of nurses are involved in the investigation process requiring the application of forensic science to nursing practice, increased collaboration with the criminal justice system is required. Forensic nursing’s scientific knowledge base emerges from theories of nursing, forensic science, criminal justice, police science, and legal studies.

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To demonstrate its roots in science, Lynch (1995) explains that the theoretical model of forensic nursing evolved from the role of the police surgeon in the United Kingdom, a practitioner of clinical forensic medicine hired by the police department and responsible for facilitating the management of the crime victim from the scene of the incident through the legal process. She writes: Forensic nursing, a clinical subspecialty, is complementary to clinical forensic medicine as it evolves in response to society’s changing demands. In the past, medicine has had a working relationship with nursing, except in forensic medicine. The time has come to extend the interdisciplinary support and assistance to include the forensic physician and forensic nurse as a cooperative unit.

Forensic nursing is the application of the nursing process to public or legal proceedings, the application of the forensic aspects of health care to the scientific investigation of trauma. Clinical forensic nursing is defined as the application of clinical nursing practice to trauma survivors or to those whose death is pronounced in the clinical environs, involving the identification of unrecognized, unidentified injuries and the proper processing of forensic evidence. Lynch writes, “A serious gap in the criminal justice system has either been left open or partially filled by health (nurses, hospital physicians, emergency medical technicians, paramedics) and justice practitioners (police officials and attorneys) who essentially lack a forensic background. These individuals must be able to recognize problems in the existing system and raise the awareness of potential solutions.” “The concept of forensic nursing science has a familiar ring to it these days, now that everybody is saying it’s not just forensic nursing, it’s forensic nursing science,” Janet Barber, MSN, FN, says: Virginia Lynch and I have heated discussions about this regularly. I tell her that nursing is a science and to say “forensic nursing science” is being somewhat redundant. Already, science is a purview of nursing, so I don’t think it adds anything more to the equation. Virginia’s idea is that the phrase addresses the scientific method and that it indicates the forensic nurse is guided by important principles of the scientific method. From that vantage point, I think it does have some validity. If using the word “science” helps nurses see the validity of the scientific processes, then I don’t have any quarrel with that. Personally, I don’t think it’s necessary, but if that word helps nurses focus on objectivity and a systematic way of gathering data, evaluating it, and drawing conclusions, then so be it.

Meliss Vessier-Batchen, RN, MSN, a nurse death investigator in Louisiana, believes the term lends added credibility at a time when forensic nursing is still proving itself. “If you look at Virginia Lynch’s earliest framework, nursing

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science is one of the three areas of the triangle created among forensic science and criminal justice,” she says. Virginia has begun using that term which I am now perpetuating because I agree with the idea—it’s not just forensic nursing, it is forensic nursing science. As forensic nurses, we bring a very scientific base to nursing. I feel strongly that forensic nursing is a science because it is based on scientific and criminal justice disciplines. That term will become more known in the future among all nurses. Forensic nursing is a science, not just a whim. It’s more than a specialty, it’s a science, growing in and of itself.

Vessier-Batchen says that it is essential for forensic nurses to conduct research and be published in respectable science-based journals to have their work taken seriously. “It’s not enough to work hard; we must produce the research that will support the claims we are making. While these claims are honest and true, there is nothing out there to support them. If we want to be considered as a true science, we must provide empirical data, and get this data out into the scientific community.” California forensic examiner Cari Caruso, RN, SANEA, says she recognizes a dichotomy between advocacy and science. “There is a way to accomplish both, but some nurse examiners find it easier to see themselves as a support person for the patient. Although I think there is a way to help patients, including referring them to victim-advocacy resources, we must keep our boundaries and be professional and highly scientific.” For example, Caruso says: If the patient is not forthcoming, or needs special attention, he or she may skew the truth; they may be covering for someone even though they are reporting the sexual assault. If the nurse examiner sides with the patient, or if the nurse sees her role as supporting the patient and their history, they are crossing a boundary line. We, as examiners, weren’t there at the time of the event, so we don’t really know what happened. We serve the patient best by maintaining our objectivity, collecting the evidence, and making sure that we don’t go overboard in our feelings. We have feelings about whether or not something is a bona fide event or not, but on the other hand, you shouldn’t go overboard, regardless. There are times when I have examined the suspect and the victim in the same case, and there are times when I find that one side or the other appears to be more credible or the retelling of the events may be more consistent, but you must maintain objectivity at all times. Recently I saw a patient who gave me kind of a quirky story about her assault that allegedly happened on a cement patio. The detective called me from the scene and told me where the assault happened; he said it was very dirty and that the cement was covered with dirt and sand. This young lady was wearing a white shirt that didn’t have a speck of dirt on it. Now that’s not very consistent. She was having some difficulty and later on it came out that there were family problems involved; the

mother told the detective that they were going to back off from the investigation. You have to let the evidence tell the story, and not be taken in by siding with the victim simply because they are the victim.

Caruso also detests the notion that forensic nurses are a bunch of bleeding hearts who do not traffic in science. “I don’t want anyone to confuse us with victim advocates,” she says. “Some people are trying to pigeon-hole forensic nurses as advocates, and while I am always an advocate for my patients’ health, we as forensic nurses should never be confused with individuals whose job it is to work purely on behalf of the victim.” A major pitfall for nurses to avoid is allowing personal beliefs to interfere with the administration of sciencebased clinical practice. Caruso says she has seen instances in which forensic nurses have withheld emergency contraception from victims due to their religious beliefs: It’s difficult for me to believe that people are still so oldfashioned or out of touch that they don’t agree with providing emergency contraception to sexual assault victims. On a SANE-hosted Web site, there was a letter from a nurse saying, “I am a Christian and I have a problem with giving emergency contraception, what should I do?” I thought to myself, “First you need to understand that it’s not an abortion; it’s emergency contraception that prevents implantation.” The bigger issue is that nurses like this need to examine whether or not their own beliefs spill over into their practice. Nurses must not push their beliefs on their patients; their job is to give them the options. A nurse would be remiss if he or she did not discuss emergency contraception with the victim. As a SANE, if you can’t objectively discuss those kinds of issues with your patients, you are doing them a disservice.

In a similar vein, Caruso frets about nurses losing their scientific sensibilities if they identify too closely with victims due to a personal history of abuse of their own: I suspect that a private history of sexual assault or abuse is the reason why a lot of nurses get into an advocacy role. I have known nurses who have been assaulted and who have entered the field of forensic nursing because of it. That can be a very real danger zone, depending on how much you are thinking of your experiences when you are dealing with your patient. That will create boundary issues, especially if a patient’s experience hits so close to home that you are going to be lost in the gray area between being a professional and relating too much to the patient’s story. There are nurses who experience vicarious trauma and burnout from becoming too involved in their patients’ situations. They must remember that they are there in a forensic capacity, a scientific capacity, not as a counselor. That’s what victim advocates are for.

Another pitfall related to nurses’ adherence to professionalism and science is the refusal or the reluctance to

Forensic Nursing as Part of the Nursing Process

perform examinations of suspects or perpetrators of violence, again, due to a need to always support the victim. Caruso continues: Some nurses balk at examining suspects, but I have always cared for suspects and victims in the same way. I don’t treat suspects any differently than I do victims, because it is not my place to pass judgment. I don’t make the suspects tell me a history per se, but sometimes I get the feeling from them that maybe they have been victimized themselves. They are all my patients and they all need a fair shake. I have had a couple of cases of really terrible child abuse and sexual abuse. I saw one suspect who just about killed a 6year-old; there was no question whether or not he had done it, as he had been caught doing it. However, he still is my patient and I didn’t treat him any differently than anyone else who would walk through my door.

Barber urges forensic nurses not to engage in undue victimology in profiling their victims or perpetrators: I think many forensic nurses started in the field as being victim oriented, but as a discipline we are trying to move away from the idea of forensic patients as being victims only; in some cases they certainly are, but in other cases they are the perpetrator of the violent act. There are many nurses who want to get into someone’s head to learn the underlying factors that would help explain why an act of violence occurred. What factors resulted in the perpetrator’s violent act? What factors contributed to the victimization of the injured? This may be important, but if it consumes the forensic investigator’s thought processes it is likely to interfere with their ability to accomplish an unbiased, complete evidentiary examination. In a one-car accident, these nurses are trying to figure out, “Were they really trying to kill themselves?” instead of noting the forensic details of the case. Instead of playing psychologist, forensic nurses should be asking themselves, “What am I seeing, what evidence do I need to collect for the experts who are going to do the analysis?” . . . That’s what forensic nursing is truly about. I think that when you start diverting your attention from documentation and evidence collection to victimology, and trying to figure out why people victimize themselves, that detracts from the goals and purpose of forensic nursing. There are many nurses who would disagree with me, but that’s OK; I would rather remain grounded in science. The difficult thing is that in the beginning, forensic nursing was based on helping people in need. We were looking at people who had been wronged, abused, neglected, assaulted, hurt in some way by an outside force, and nurses thought, “These poor people, something bad happened to them and we have to go pick up their shattered bodies and lives and get them back on the road.” Now, forensic nursing has evolved to where we must compartmentalize our desire to care for, nurture, console—any nurse would do that, forensic nurse or not, because caring for and protecting human beings is instinctive. The forensic component of nursing comes to the forefront, the science of identifying, gathering,

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managing, preserving, and documenting evidence properly for others to analyze. The advocacy component is not unique to forensic nursing; it is within every nurse’s purview, but the forensic nurse really cannot get overtly involved in advocacy. This nurse must stay within an objective, scientific framework, because if a nurse allows advocacy to supersede concern about the evidence, he or she will become diverted from the purpose of forensic nursing. Some nurses cannot function well in a forensic capacity because they become emotionally overwrought by the cases they see, and their objectivity is compromised. They have such an emotional reaction to patients that they forget what they are there for, and what they are there for is to gather scientific evidence and other objective information from which analytical experts can interpret and draw conclusions.

Arizona forensic nurse Mary Sullivan, MSN, RNC, CARN, a strong proponent of science-based nursing practice, concurs. “The forensic nurse must operate from a base of science at all times,” she emphasizes. We can do victims a better service by putting on our forensic caps and being unbiased in our work. If not, we do the entire forensic nursing community a disservice. The forensic community is all about science. We will gain greater recognition as a nursing specialty through continued good performance, leading by good example, and through patience and tenacity. I think nurses must stay scientific and not align themselves with victims’ organizations or advocacy roles. We will do more for the patients by being scientific and approaching our work as a forensic scientist would approach his or her work. In our hearts we can be pleading for the patient and doing our work for them, but as a forensic scientist, we must be unbiased and careful in our work. I think, in the long run, that will achieve greater recognition and results for victims and for our profession, and the rest of the scientific community would respect us for it. When you put on your forensic hat, you are not an advocate for the patient, you are an advocate for truth and justice. When I took the SANE training, for example, I was taught that you are there to collect the evidence. You are not there to make the case for the victim. You are there to gather the facts as professionally and accurately as you can, and to follow forensic protocol. You are not there to support the victim or hold her hand, as there are advocates expressly to fill that role. It is this way because when a forensic nurse goes to court, he or she must be scientific and be above reproach.

California forensic examiner Sharon Crowley, MN, RN, also believes nurses must approach their work from a strong grounding in science: I feel that as a nurse, as a person, as whatever I am, I feel that my biggest contribution to the victim’s cause is to do the best job I can in the world of forensics. It’s a scientific

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Forensic Nursing

endeavor, period. There’s nothing to argue about. What I do as a forensic nurse is going to be dissected in a court of law, or dissected in a crime lab, and that’s fine. Labs need science, courts like science, and we know juries admire science. My biggest contribution as an individual who happens to be a nurse is that I can make my best advocacy through scientific work. If I chose to be an advocate as a rape crisis counselor, that would be my best contribution, and I think there should be that distinction. I don’t have a problem with it because I see my advocacy come through science. It’s not personal. I have had feedback from victims who say they appreciate that approach, because it’s what they need to help prosecute their case. I think there are others who can fill the advocacy role very well. If a nurse chooses to be an advocate, God bless him or her, but I don’t think that nurse should consider himself or herself to be operating in a medico-legal capacity, because it’s no longer science. Forensic nursing practice is not mandated by advocacy, it is mandated by science. While crimes such as sexual assault are interpersonal cases, the outcome and the way they are handled are based on scientific evidence. How victims recover is an issue separate from forensic nursing’s goal to document injury and collect evidence. The best thing I can do for the patient is do my scientific work and still provide them with warmth, caring, and nurturing; that’s the nurse part of me, and nurses do that best. But I am also a scientist. We have this unique capability to combine the best of both approaches in a service to victims.

Crowley says she struggles with the advocacy versus science dilemma in her work in sexual-homicide cases: I know what I am attempting to prove is valuable to the scientific community, to the courts, and to law enforcement, but what is it doing for the victim’s family? Who in their right mind would want to know, “By the way, not only has your loved one been murdered, but they have been sexually molested, too”? But then a victim’s mother once thanked me for being able to offer the courts scientific evidence. To me, that answered my question without a doubt, and it gave me permission to pursue my work because I could still feel like I am advocating in my own way, through science. I don’t think we, as forensic nurses, do people any favors by saying “Everything’s going to be OK,” because that’s what a victim advocate is there to do. We are there to be scientific.

The AAFS has been open to the development of a forensic nursing section, overseen by at least a dozen designated fellows who have the credentials, the experience, and the requisite credibility as mandated by the academy. Many nurses, like Sullivan, see membership and fellowship in the academy as a sign that forensic nurses have arrived and are accorded the same level of professional respect afforded to other members of the forensic science community. It is a validation that has been a long time in coming, nurses say, but there has been a lack of

nurses who have what it takes to reach this professional peak. Sullivan observes: It’s simply a matter of nurses doing the work it takes to achieve that level in the academy. Yes, it can take as long as eight, nine, 10 years. Nurses need to get busy and take care of business, and work the various levels in the academy. They must present, participate, attend meetings, and do whatever it takes to show the academy that they take their work seriously. Nurses must continually improve their skills, and be aware of how they are perceived by the general forensic science community. As a whole, the forensic nursing community has not yet achieved consensus on everything it believes. And it will never gain the credibility and respect in the academy until it does. The nurses who are going to be accepted into the academy will play by the academy’s rules, and they will prove themselves by the academy standards; those nurses will gain credibility and respect. Very simply, being a victim is not going to cut it with the academy. If we call our conferences scientific assemblies, they better be scientific. The same goes for our practice.

Crowley believes that nurses must continually work on raising their credibility quotient. “As nurses, we have always had to work harder to prove our mettle. I don’t have a problem with that, as I think it’s kind of fun to be challenged and rise to the occasion. Who wouldn’t want to rise to excellence and do awesome things? As forensic nurses, that’s our birthright.” Crowley says she still laughs when she faces the absurdity of old issues of gender or occupational discrimination: Nurses today still deal with feminist-like issues that were raging 30 years ago. We are still fighting the same battles of equity and competence, but that means we have to be better than we ever think we can be. It means excelling in nursing practice and being the very best that we can be, because we face enormous scrutiny. To get to the next level, forensic nurses must conduct research to thoroughly understand the issues. To play with the big boys, you have to hold your own. You have to do your homework, you have to keep up with the literature, and gee, maybe even contribute to the literature! The take-home message is, because forensic nurses are relatively new, we stand out, and we are being watched. So we must be prepared, and we must be impeccable in our practice.

As someone who has been published in prestigious scientific journals and has presented her research to numerous important scientific gatherings, Crowley knows the importance of nurses contributing science-based, evidence-based material to the current body of forensic science thought. Although they might not represent all of the goals of forensic nurses, these professional accomplishments propel the collective discipline forward, and

Forensic Nursing as Part of the Nursing Process

help it create traction among the other sciences. Crowley emphasizes the importance of buy-in from the scientific community: None of us works in a vacuum. Forensic nurses need the greater forensic science community to help validate and recognize our work and our contributions. Once you get through the barrier of “you’re just a nurse,” which you can refute by your professional integrity and your performance, they will come around. Sometimes nurses are too busy trying to impress each other, when we need to concentrate on impressing the larger scientific community. When I wrote my book, when I submitted my research for publication . . . each time I had to prove myself. And that’s OK, because it makes you reach inside yourself and want to show them what you can do. We need to prove to the scientists that we can be scientific, too. That’s why I chose to publish in the Journal of Forensic Science. I think I am the first nurse to be a solo author in the JFS, and that’s fun. But I had to fight some battles along the way, just like I did as a young nurse in my 20s. Once I wrote the article, it was time to work through the acceptance process. I could see from the beginning that the editor was in my court, but when it went out for blind peer review, some of their comments were the same I’d heard all my life about nurses. One of the reviewers said, “I could see where nurses should be allowed to examine living victims but I don’t know if they should be examining post-mortem cases.” I had to laugh, because SANEs fought this battle 15 years ago to examine living victims, and here I am hearing the same argument now. Another reviewer said, “Maybe you should have a physician as a co-author,” and I thought, that’s not going to happen—I’d rather not be published. I went through this with my book, too. It was the same old issue of yes, I’m “just” a nurse, and I’m happy with that, and yes, we can do things like publish our research, and then suddenly, “Wow, I’ve been published!” But it was a proving ground. I had to continually explain why nurses are qualified to do what they do, and that no, we’re not trying to step on the toes of forensic pathologists or anybody else—we are simply trying to live up to our capacities as nurses. Some have asked, “How could a nurse be the one to go to a crime scene?” You can attend the annual AAFS meeting and you’ll hear nurses say how they essentially do the entire crime scene, or the entire forensic protocol, and here I am writing a protocol and I’ve been criticized because I want to publish something that says a nurse should be able to collect the clothing as evidence . . . it can be unbelievable how many times we have to defend what we have a right to do, but then again, that has always been the nurse’s burden. You have to reassure them, and catch flies with honey, not vinegar. I’ve done it as a nurse for more than 30 years, and even more so in forensics, but

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when you get those flies, believe me, they stick with you. They may be slow to come on board, but once they’re on your side, they’ll back you. For that reason, science is so very important. It’s a scientific field, and forensic nurses must see themselves in that light. That’s an awesome responsibility, but I think we’re up to it. I know of a pathologist now who thinks forensic nursing is awesome, but I had a hard time convincing him in the beginning. It was probably all of my sweet talking and convincing and demonstrating my abilities. I’ll go to my grave never knowing exactly what worked, but as long as it worked, I’m good with it. And hopefully, if we all make these kinds of inroads into the scientific community, future generations of forensic nurses will have it easier than we did.

Crowley recalls a moment in her life when she realized she had “arrived.” She says, The academy has been so supportive and really wonderful to me as a nurse and as a member. At one of the meetings, my book was there, and I was walking along the vendor’s booth, peeking at it . . . this was just after it had come out and I was so excited. I overheard two forensic pathologists talking; one of them said, “Yeah, that’s such and such a book, it was written by a nurse, but she really knows what she is talking about.” And I thought, “Oh my God, that’s it in a nutshell.” That’s what you deal with daily . . . yeah, you’re a nurse, and wow, you happen to be good at it. You can’t let those kinds of comments bother you; you must be able to say, “That’s cool, I’m just a nurse.” And deep down you know your own worth. Or when you’re on the witness stand in court and they try to attack you by saying “You’re just a nurse,” you have to be able to embrace that moment and say, “Yeah, isn’t that cool?” And then show them your stuff.

REFERENCES Barrow, J. Theories of Everything. New York: Oxford University Press, 1991. Bemis, P. A. Psychiatric Emergency and Suicide Attempt. NursingCEU.com. 2003. Bright, W. E. An Introduction to Scientific Research. McGrawHill, 1952. Carroll-Johnson, R. M., & Paquette, M., Eds. Classification of Nursing Diagnoses: Proceedings of the 10th Conference. Philadelphia: J. B. Lippincott. 1994. Lynch, V. A. Clinical forensic nursing: A new perspective in the management of crime victims from trauma to trial. Critical Care Nursing Clinics of North America. 7, 3, 489–507, 1995. Lynch, V. A. Clinical Forensic Nursing: A New Perspective in Trauma. Collins: Bearhawk Consulting Group. 1997. McCloskey, J. C., & Bulechek, G. M., Eds. Nursing Interventions Classification (Third Edition). St. Louis, MO: Mosby. 2000.

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3 The Mandate for Forensic Nursing CONTENTS 3.1 The Scope of the Problem: 2002 and 2004 Crime Reports ................................................................................... 33 3.2 The Response to Violence by the Joint Commission on the Accreditation of Health Care Organizations .......... 36 3.3 The Response to Violence by the Public Health Community ................................................................................ 38 3.4 Is There a Forensic Nurse in the House?................................................................................................................ 40 References ......................................................................................................................................................................... 40 Recommended Readings ................................................................................................................................................... 41

Although nurses are not crime fighters or armchair detectives, they play an important role in the criminal justice system by assessing, treating, and documenting injuries of victims and perpetrators of crime. Few would argue the fact that crime is a by-product of modern life, and the potential for new ways to inflict harm grows with the times. Bioterrorism, escalating conflict, and immigrant influxes all contribute aggravating factors to crime-rate escalation. Additional factors that influence crime rates include the strength of law enforcement agencies and other components of the criminal justice systems (prosecutorial, judicial, correctional), as well as citizens’ attitudes toward crime, population density and degree of urbanization, and economic conditions, including income, poverty level, job availability, and education of its citizens. Health care facilities are the frontline recipients of both victims and perpetrators of crime. It only stands to reason that reinforcing a facility’s infrastructure to handle an increasing number of these individuals begins with the presence of an individual or team of individuals thoroughly and firmly entrenched in forensic principles. Lynch (1997) writes, “Due to the vast number of crime victims presenting in acute-care settings, the need for forensic specialists has been recognized. Forensic nurses do not compete with, replace, or supplant other practitioners; rather, they fill voids by accomplishing selected forensic tasks concurrently with other human-caring measures.” Bell and Benak (2000) say that violence is defined as any human action resulting in injury or abuse, and generally of the interpersonal variety rather than acts resulting from war or natural disaster; it is a pervasive, deceptive force that destroys the basic human foundation in society. They point to a greater awakening in 1985, when thenSurgeon General C. Everett Koop identified the impact of violence as a health care issue, calling for new public attitudes and programs addressing the needs of victim survivors. Bell and Benak write, “Victims of violence most

often present to a public servant (including police, fire, emergency medical services, and health care personnel) for intervention and/or medical treatment. Violence crosses all economic and cultural boundaries and presents an unprecedented challenge to the public servant, as the public expects professionals to be well-prepared to manage forensic issues, the resultant outcome of violence.” They reason that forensic nursing is a logical way to address violence and its by-products. They add: Traditionally, forensic content has not been included in the basic education of public servants. The unfortunate reality is that these professionals are not adequately prepared to manage the results of violent situations. The forensic evidence that is associated with an act of violence often goes unrecognized by health-care providers and is therefore lost. Successful prosecution of perpetrators of violence becomes difficult without physical evidence to corroborate a victim’s story and circumstance.

3.1 THE SCOPE OF THE PROBLEM: 2002 AND 2004 CRIME REPORTS The Criminal Victimization, 2002 report of the U.S. Department of Justice’s Office of Justice Programs in the Bureau of Justice Statistics (BJS) was released in August 2003. This National Crime Victimization Survey (NCVS), compiled by BJS statisticians Callie Marie Rennison, PhD, and Michael R. Rand, revealed long-term declines in victimization to the lowest per-capita rates in nearly 30 years. Overall violent victimization rates in 2002 were the lowest recorded since the inception of the NCVS in 1973. In 2002, U.S. residents age 12 or older experienced about 23 million violent and property victimizations, according to the NCVS, including 5.3 million violent crimes (rape, sexual assault, robbery, aggravated assault, and simple assault), which continued a downward trend 33

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Forensic Nursing

that began in 1994. Between 1993 and 2002, the violent crime rate decreased 54 percent, from 50 to 23 victimizations per 1,000 persons age 12 or older. In 2002, victims reported to police 49 percent of the violent crime they experienced, up from 43 percent of crimes reported since 1993. The NCVS collects data on nonfatal crimes against persons age 12 or older, reported and not reported to the police, from a nationally representative sample of U.S. households. Information on homicide comes from the Uniform Crime Reporting (UCR) program of the FBI. The violent crime rate declined somewhat from 25 to 23 victimizations per 1,000 persons from 2001 to 2002. Aggravated assault rates fell significantly, and rape and sexual assault rates did not change from 2001 to 2002. Based on preliminary 2002 data from the FBI, the number of persons murdered in the United States increased 0.8 percent between 2001 and 2002. In 2001, 15,980 persons were murdered; the estimate for 2002 was about 16,110 murder victims. Preliminary data suggested that increases in the number of murders occurred in the south (+2.1 percent) and the west (+5.2 percent). Declines in the number of murders were measured in the northeast (–4.8 percent) and the Midwest (–2.8 percent). In 2001, the year in which the most recent comprehensive data was available, the FBI reported a total of 15,980 murders or nonnegligent homicides. That total represents a 1.3 percent increase from the 15,586 murders recorded in 2000. The FBI defines murder in its annual Crime in the United States report as the willful (nonnegligent) killing of one human being by another. Not included are deaths caused by negligence, suicide, or accident; justifiable homicides; and attempts to murder or assaults to murder, which are scored as aggravated assaults. The FBI’s UCR program gathers murder statistics from more than 17,000 city, county, and state law enforcement agencies. Although the rate and level of homicide changes year to year, the relationship between victim characteristics and homicide tends to remain the same. For example, as in previous years, in 2001: • •

•

• • •

Most murder victims were male (76 percent). When the race of the murder victim was known, about half were White (49.1 percent), and about half were Black (46.9 percent). When information on the victim–offender relationship was available, 76 percent of the offenders were known to the victim, and strangers murdered 24 percent of victims. Firearms were used in the majority of murders (63 percent). Offenders were most often male (90 percent), and most often adults (92 percent). Homicide generally is intraracial.

• •

Arguments were the most often cited circumstance leading to murder (28 percent). Homicides occurred in connection with another felony (e.g., robbery or narcotics) in 17 percent of incidents.

Comparing two-year average annual rates showed that for every category of crime except rape and sexual assault, the average annual rates were significantly lower in 2001–2002 than in 1999–2000. The average annual rate of rape and sexual assault was slightly lower in 2001–2002 than in 1999–2000. The average annual overall violent victimization rate declined 21 percent from 30 to 24 victimizations per 1,000 persons per year from 1999–2000 to 2001–2002. During the same time, aggravated assault rates fell 23 percent. The rate of violent crime experienced by males, females, Whites, Blacks, and non-Hispanics fell significantly from 1999–2000 to 2001–2002. The rate of violence against Hispanics fell somewhat during the same period. Rates of violent victimization remained statistically similar between 1999–2000 and 2001–2002 for persons of “other” races. Violence against never married, married, and divorced or separated persons fell in 2001–2002 compared to 1999–2000. For persons under age 35 and those between ages 50 and 64, violent crime fell significantly from 1999–2000 to 2001–2002. A slight decline was measured for persons between ages 35 and 49. No change in the rate of violent victimization against persons age 65 or older was measured between 1999–2000 and 2001–2002. Violent crime decreased in every region and type of area of the nation over the same time period. The rate of every major violent and property crime measured in the NCVS—rape and sexual assault, robbery, aggravated assault, simple assault, burglary, theft, and motor vehicle theft—fell significantly between 1993 and 2002. The overall violent crime rate fell 54 percent from 50 to 23 violent victimizations per 1,000 persons age 12 or older between 1993 and 2002. Other significant declines were measured in rates of rape and sexual assault (down 56 percent), aggravated assault (down 64 percent), and simple assault (down 47 percent). Females were most often victimized by someone they knew, whereas males were more likely to be victimized by strangers during 2002. Of those offenders victimizing females, 40 percent were described as friends or acquaintances, 20 percent as intimates, and 7 percent as some other relative. Strangers to the victim committed 31 percent of the violence against females. In contrast, of those offenders victimizing males, 37 percent were described as friends or acquaintances, 3 percent as intimates, and 4 percent as some other relative. Strangers committed 56 percent of the violence against males. During 2002, 71 percent of all violent crime victims did not face an armed offender. However, the presence of

The Mandate for Forensic Nursing

a weapon during a violent crime was related to the type of crime. For example, rape and sexual assault victims were the least likely (7 percent) and robbery victims the most likely (46 percent) to face an armed offender. The type of weapon also varied according to the type of violence. Four percent of victims of rape and sexual assault faced an offender armed with a firearm, compared to 25 percent of robbery victims. An offender brandishing a knife confronted 2 percent of rape and sexual assault victims and 12 percent of robbery victims. During 2002, 49 percent of all violent victimizations were reported to the police. The violent victimization of a female was more likely to be reported to the police than was the victimization of a male during 2002. In October 2004, the FBI released crime figures for 2003—the latest data available at the time of writing—that showed that violent crime in the United States declined 3 percent from the estimated volume in 2002. Further, the five- and 10-year trend data indicated that the volume of violent crime declined 3.1 percent from the 1999 estimate and 25.6 percent from the 1994 estimate. A comparison of 2002 data to 2003 data showed that the rate of violent crime, estimated at 475 violent crimes per 100,000 inhabitants, decreased 3.9 percent in 2003. These results are from the FBI report, Crime in the United States, 2003. At nearly 1.4 million offenses, the estimated volume of violent crime in the United States in 2003 declined 3 percent from the 2002 figure. In 2003, the offense of murder was the only violent crime to show an increase in volume (1.7 percent) compared to the 2002 data. Collectively, U.S. cities experienced a 3.9 percent decrease in violent crime in comparison to the 2002 figure. Violent crime decreased 3.7 percent in the nation’s nonmetropolitan counties and 1 percent in metropolitan counties. Approximately 30.7 percent of violent crimes were committed with personal weapons such as hands, fists, feet, and so on. Perpetrators used firearms in 26.9 percent and knives or cutting instruments in 15.2 percent of violent crimes. Other weapons were used in 27.3 percent of violent offenses during 2003. The UCR Program estimated that in 2003 law enforcement agencies nationwide made 597,026 arrests for violent crime, accounting for 4.4 percent of the estimated number of all arrests. Law enforcement agencies nationwide solved 46.5 percent of violent crimes in 2003. By offense type, agencies cleared 62.4 percent of murders, 55.9 percent of aggravated assaults, and 44 percent of forcible rapes. Nationally in 2003, 12.2 percent of violent crime clearances involved only juveniles. Among the population groups, 12.2 percent of violent crime clearances in cities collectively involved only juveniles; 12.7 percent of violent crime clearances in metropolitan counties and 9.8 percent in nonmetropolitan counties involved only juveniles.

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In 2003, law enforcement collectively reported an arrest rate of 5,109.3 arrests per 100,000 inhabitants. Law enforcement agencies in U.S. metropolitan counties made 3,731 arrests per 100,000 in population; law enforcement agencies in nonmetropolitan counties made 3,961.2 arrests per 100,000 in population. Compared to the data from 2002, the number of arrests in 2003 showed a slight increase (0.2 percent). The number of arrests for violent crime in 2003 decreased 2.3 percent; the number of arrests for property crime increased 0.7 percent. Adults comprised 83.7 percent of all arrestees in 2003. By gender, 76.8 percent of those arrested in the United States were male. Compared to the 2002 data, the number of males arrested in 2003 declined 0.4 percent, whereas the number of females arrested in 2003 increased 1.9 percent. An examination of arrestee data by race indicated that 70.6 percent of those arrested in the United States in 2003 were White. The UCR Program estimated that 16,503 murders occurred in the United States in 2003, representing a 1.7 percent increase from the 2002 estimate. Law enforcement agencies provided the UCR Program with supplementary data for 14,408 murders in 2003 showing that most murder victims (90.6 percent) were adults and most were males (77.6 percent). Of the male murder victims, 8.2 percent were juveniles (persons under the age of 18). Juvenile females comprised 13.5 percent of female murder victims nationwide. By race, 48.7 percent of murder victims were White, 48.5 percent were Black, and the remainder was of other races. In 44.5 percent of murders, the relationship of the murder victim to the offender was unknown. Of the 55.5 percent of murders in which the victim–offender relationship was known, 77.6 percent of the victims knew their assailants. In those murders for which law enforcement personnel reported victim and offender relationship data, 32.3 percent of females were killed by their husbands or boyfriends, and 2.5 percent of males were killed by their wives or girlfriends. Of the murders involving a single victim and a single offender, 92.4 percent of Black victims were killed by Black offenders; 84.7 percent of White victims were killed by White offenders. Of the murders in 2003 for which law enforcement identified the type of weapon, nearly 70.9 percent involved firearms. Offenders used knives or cutting instruments in 13.4 percent of murders; personal weapons such as hands, fists, and feet in 7.0 percent of murders; and blunt objects in 4.8 percent of murders. Four percent of murders were committed with other types of weapons. In 2003, law enforcement investigation was unable to determine the circumstances in 33.9 percent of murders in the nation. The supplementary data also showed that 16.4 of murders were committed during the commission

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of another felony, such as during a robbery or a violation of a narcotic drug law. An estimated 93,433 forcible rapes occurred in the United States in 2003, representing a 1.9 percent decrease from the 2002 estimate. The UCR estimated that 63.2 of every 100,000 females in the United States were victims of forcible rape in 2003. This rate represented a 2.7 percent decrease from the 2002 rate. By community type, the rate of forcible rape in the U.S. Metropolitan Statistical Areas (MSAs) was estimated at 64.5 forcible rapes per 100,000 females. There were an estimated 75.1 forcible rapes per 100,000 females in cities outside MSAs and 45.7 forcible rapes per 100,000 females in the nation’s nonmetropolitan counties. For the 10th consecutive year, the estimated number of aggravated assaults in the United States declined. Based on law enforcement reports for 2003, the UCR estimated 857,921 aggravated assaults, a 3.8 percent decrease compared to the 2002 figure. By volume, aggravated assaults comprised 62.1 percent of the estimated total number of violent crimes. By rate, the UCR estimated that there were 295 aggravated assault offenses per 100,000 inhabitants in the United States, a 4.7 percent decline from the 2002 estimate. Aggravated assault offenders used personal weapons (hands, fists, feet, etc.) in 26.9 percent of offenses, firearms in 19.1 percent of offenses, and knives or cutting instruments in 18.2 percent of offenses. Other types of weapons were used in 35.9 percent of aggravated assaults.

3.2 THE RESPONSE TO VIOLENCE BY THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS Although the U.S. crime rate will always fluctuate, there is little doubt that violence will continue to be a part of everyday life. As such, and recognizing that the health care system will be called on to care for the victims and perpetrators of violence, one important oversight entity has led the way in developing standards aimed at addressing this complex issue. Since 1992, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has published standards to ensure that all staff at its accredited hospitals hospital are trained in the identification of victims of violence and protocol necessary to treat and care for these individuals. These standards include criteria to identify potential victims of physical assault, rape, or sexual molestation, as well as provide guidance for patient evaluation procedures, including patient consent, examination components, and treatment. Lynch (1995) writes:

Forensic Nursing

A mandate that unequivocally provides for the role of the forensic clinician is set forth in the hospital’s responsibility in collection, retention, and safeguarding of specimens, photography, and other trace and physical evidence. Medical record documentation, including examinations, treatment referrals to other care providers and community-based family violence agencies, and required notification of authorities, are among the responsibilities of the care provider.

JCAHO also monitors its accredited health care institutions’ response to adverse (sentinel) events. JCAHO is a not-for-profit entity that provides accreditation to acute-care facilities; it evaluates and accredits more than 16,000 health care organizations and programs in the United States and is the nation’s predominant standards-setting and accrediting body in health care. The JCAHO standard relevant to forensic nursing is PC.3.10.1. According to Mark Forstneger, media relations specialist for JCAHO, there are no current plans to revise these standards, which were updated for 2004 as part of the “Shared Visions, New Pathways” standards review project. Sullivan (in press) says that these standards “open the door for an important role to include the clinical forensic nurse specialist or investigator.” PC.3.10.1 mandates that victims of sexual molestation, domestic abuse, elder neglect or abuse, and child neglect or abuse are identified using criteria developed or adopted by the hospital. This standard acknowledges that these medico-legal cases have subtle clinical presentations that might not be obvious to untrained personnel; therefore, every health care institution must have in place methodology to assist medical personnel in the identification and assessment of these patients, no matter to which hospital department they first present. Following assessment, the health care provider must determine an appropriate course of treatment or referral, bearing in mind that JCAHO requires what it deems to be observable evidence as opposed to allegations. Sullivan (in press) writes, “With the influence of forensic science on nursing assessments made by the clinical forensic nurse provider, it is more likely that a patient who is a victim of domestic abuse or neglect will be discovered. With this discovery, the appropriate assessments, documentation, and referrals will be made in a timely manner.” Because JCAHO mandates that health care providers conduct their evidentiary examinations and assessments within a medico-legal context, Sullivan believes that the clinical forensic nurse examiner “is the ideal person to collect and preserve all evidentiary material in these clinical situations. This nurse is particularly knowledgeable about the safeguarding of evidence and chain-of-custody requirements that are paramount in all cases that involve legal action. Further, this nurse should be involved in

The Mandate for Forensic Nursing

writing all policies and procedures that define these activities within the hospital setting.” Specifically, JCAHO Standard PC.3.10.1 states that victims of abuse, neglect, or exploitation might come to an organization in a variety of ways. The patient might be unable or reluctant to speak of the abuse, and it might not be obvious to the casual observer. Staff must be able to identify abuse, neglect, and exploitation as well as the extent and circumstances of the abuse, neglect, or exploitation, to give the patient appropriate care. Criteria for identifying and assessing victims of abuse, neglect, or exploitation should be used throughout the organization. The assessment of the patient must be conducted within the context of the requirements of the law to preserve evidentiary materials and support future legal actions. Elements of performance for PC.3.10.1 include the following: 1. The organization develops or adopts criteria for identifying victims in each of the following situations: • Physical assault • Rape • Sexual molestation • Domestic abuse • Elder neglect or abuse • Child neglect or abuse • Exploitation 2. Staff is educated about abuse, neglect, or exploitation and how to refer as appropriate. 3. A list of private and public community agencies that provide or arrange for assessment and care of abuse victims is maintained to facilitate appropriate referrals. 4. Victims of abuse, neglect, or exploitation are identified using the criteria developed or adopted by the organization at entry into the system and on an ongoing basis. 5. The organization’s staff refers appropriately or conducts the assessment of victims of abuse, neglect, or exploitation. 6. All cases of possible abuse, neglect, or exploitation are reported to appropriate agencies according to organization policy and law and regulation. State laws differ for child abuse, intimate partner violence, and elder abuse. Some states have requirements to report current victimization to law enforcement or social services. Providers should: • Learn applicable state statutes. View state codes specific to domestic violence. • If you practice in a state with a mandated reporting law, inform patients about any lim-

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its of confidentiality prior to conducting screening. 7. All cases of possible abuse, neglect, or exploitation are immediately reported in the organization. “I believe that the Joint Commission’s standards addressing victims of abuse and violence are beginning to be viewed by all health care providers as something they must keep in the forefront of their minds,” says Janet Barber, MSN, RN: The Joint Commission has the authority to say to health care professionals, “You have a role in this, you must assess patients for abuse and neglect, you must intervene, you must refer, you must care for them, and you must manage evidence according to your community’s standards.” I think the fact that the Joint Commission basically has said to hospitals, “This is no longer optional; whether you want to or not, you will be involved in this process,” demonstrates what good citizenry in the health care field is all about. On other health care fronts, other practitioners in nursing subspecialties have been picking up various bits of forensic protocol and practice; psychiatric nurses, pediatric nurses, OB-GYN nurses, and nurse gerontologists are beginning to see clearly how they fit into this whole realm. I think that this trend is encouraging, and it helps to further support and legitimize forensic nursing.

Because it is considered to be the gold standard for accreditation, a stamp of approval from the JCAHO carries weight in the health care community. It also appeals to third-party payers, insurance companies, and the consumer seeking exemplary health care. The managed care era has slashed reimbursement rates and created enormous competition among health care systems, so many institutions are looking for ways to differentiate themselves in the marketplace. Accreditation by the JCAHO and a progressive response to patients, especially those sustaining trauma or abuse, helps to meet that goal of providing distinguished services. “Even hospitals who do not seek Joint Commission accreditation primarily because of cost restrictions pay attention to what JCAHO says because it’s the gold standard,” Barber says. “They read the manuals and they are familiar with JCAHO’s mandates even though they do not seek accreditation. So when you consider the number of hospitals who are following JCAHO’s mandates, there are an incredible number of hospitals who are poised to take it a step farther and employ forensic nurses to help them meet these standards.” Barber says she observes an increasing number of developments in health care that can be linked to forensic practice, including mandatory reporting of certain kinds of deaths, as well as long-standing requirements to report abuse:

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For example, the Centers for Disease Control and Prevention (CDC) has introduced a data form to record information gained during the investigation of SIDS deaths, and so I think an increasing number of agencies such as the CDC are beginning to realize the importance of quantifying data and statistics related to such medico-legal cases. Because information about these kinds of deaths is statistically vital to the government, health care institutions can no longer be apathetic about how they investigate and classify these deaths. Health care personnel can no longer say casually, “That was a natural death” or “That was an accidental death,” or “That was a death stemming from intentional abuse and neglect,” without the data and the evidence to back it up. This means institutions will have to pay far more attention to these issues, and that’s a good thing for forensic nursing practice. Mandatory reporting and new assessments and new ways of collecting data may not directly support forensic nursing practice, but I think an increasing number of people see more clearly that in a health care institution, the nurse is the constant in the medico-legal equation. Social workers come and go, doctors are there for brief periods of time, and all other practitioners who interface with patients are fairly transient. But the nurse is the ever-present person who can put a lot of details together and who has that around-the-clock vigilance. Nurses are the keepers of the keys, so to speak, and this will heighten their visibility as various agencies continue to address issues related to violence and death.

In addition to recognizing victims of violence, hospitals must address sentinel events, defined by the JCAHO (2004) as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Sullivan (in press) writes: Each hospital is to establish mechanisms to identify, report, analyze, and prevent these events and are expected to identify and respond appropriately to all sentinel events. Response includes conducting a timely, thorough, and credible root cause analysis; implementing improvements to reduce risks; and monitoring the effectiveness of those improvements. Utilizing the expertise of a clinical forensic nurse will assist hospitals with fulfilling these standards.

3.3 THE RESPONSE TO VIOLENCE BY THE PUBLIC HEALTH COMMUNITY In “Strengthening the Collaboration Between Public Health and Criminal Justice to Prevent Violence,” published in the Journal of Law, Medicine & Ethics, ProthrowStith (2004) reports that public health has made several contributions to the understanding and prevention of violence, including new and expanded knowledge in surveillance, delineation of risk factors, and program design, including implementation and evaluation strategies. She writes, “While public health activities generally comple-

ment those of criminal justice, confrontations, challenges, and turf issues within this cross-disciplinary enterprise remain inevitable. Continued progress is dependent upon expanded efforts and greater collaboration within both disciplines.” Prothrow-Stith explains the four reasons why interpersonal violence (IPV) became an important concern for public health professionals in the United States: 1. The contact health professionals have with victims and perpetrators of violence 2. The magnitude of the problem 3. The characteristics of violence 4. The application of public health strategies to both understanding and preventing violence, which has yielded significant positive findings and offers further promise According to Prothrow-Stith, 30 years ago, emergency room personnel had a “stitch them up and send them out” mentality as the standard of care. She writes, “Nevertheless, the predictable and regular contact physicians and nurses have had with victims and perpetrators of violence, particularly in emergency departments, has caused many to begin to address this problem. To this day, emergency room recidivism and the high mortality rates associated with violent injury continue to compel medical personnel toward violence prevention efforts.” Since the late 1980s, Prothrow-Stith reports that the ACEP has included violence prevention on the agenda of its annual meetings, and that the American Medical Association (AMA) has published protocols and manuals for health care providers on domestic violence, youth violence, child abuse, and sexual assault. With a greater awareness has come new strategies, materials, and protocols for clinical intervention and prevention, thus “reflecting the responsiveness of health care providers to the repeated contact they have with the tragedy of violence,” she adds. In the past 20 years, public health professionals have applied traditional public health strategies to violence prevention. Prothrow-Stith writes, “They have brought a different perspective and orientation to bear on the problem by applying public-health techniques and strategies which complement and strengthen the criminal justice approach. Public health brings an analytic approach that identifies risk factors and important causes that could become the focus of preventive interventions.” A definition of violence within the public health profession was offered by the National Center for Injury Prevention and Control at the CDC. The CDC classifies both unintentional injuries (accidents) and intentional injuries (violence) as public health problems. Intentional injuries are divided into self-directed violence (suicides and suicide attempts) and IPV (assaults and homicides).

The Mandate for Forensic Nursing

Violence is defined by the CDC, as “the threatened or actual use of physical force or power against another person, against oneself, or against a group or community that either results or is likely to result in injury, death, or deprivation.” Prothrow-Stith writes that in the last 20 years, “Violence has been increasingly accepted within mainstream public health as a problem for its consideration. The major contribution resulting from designating violence as a public health problem is the acknowledgment that violence is preventable, not inevitable.” In 1983, the CDC established its Violence Epidemiology Branch for the explicit study of homicide and suicide. Prothrow-Stith calls this application of basic epidemiology and reporting techniques “part of the impetus for public health professionals across the country to confront the issue.” Two years later, thenSurgeon General C. Everett Koop convened the Surgeon General’s Workshop on Violence and Public Health, which looked at assault, homicide, child abuse, rape and sexual assault, domestic violence, elder abuse, and suicide. In 1994, the CDC created the National Center for Injury Prevention and Control and every surgeon general to follow Koop has encouraged the public health community to better understand and prevent violence. Prothrow-Stith asserts that public health’s venture into violence prevention “has not always been well received,” adding that numerous issues divide public health and criminal justice, including proactive versus reactive strategies, and prevention efforts versus a punitive response to violence. She says that the public health and criminal justice systems have been historically separate in their conceptualization of approaches to violence and the development of activities to reduce or prevent violence. She writes, “The public health field has approached the issue through efforts to identify the risk factors related to violent behavior. The criminal justice system has approached the issue through efforts to identify and assign blame for criminal behavior, maintain public safety, and remove violent offenders from the community.” She states that the criminal justice system’s response to violence is rooted in the assumptions that violence is an individual’s criminal choice; punishment or the threat of punishment is a deterrent to violent acts; and violence is an inevitable aspect of the behaviors of some people. She adds that prevention of violence is resolved through the “passage of laws and the deterrence resulting from enforcement.” Prothrow-Stith is concerned that the criminal justice system does not adequately address violence among intimates. She explains, “Police and many of the laws they enforce are geared toward predatory violence that occurs among strangers on the street. As a result, the many episodes of violence among family, friend and acquaintance that emerge from insults, frustrations, festering disputes, and that take place in intimate settings are less well

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addressed.” She advocates for a more collaborative and comprehensive set of prevention activities to address acquaintance violence. She writes, “More effective collaboration beyond the existing silos of activity and competitive strategies would greatly improve society’s capacity to save children from the devastating impact of interpersonal violence. Currently, both disciplines are defensive; criminal justice for its failure to meet societal expectations to control youth violence and public health for the slowness with which it has recognized and taken on the problem.” She adds that tension between the two disciplines is inevitable, fueled further by divergent perspectives and inadequate resources directed to addressing violence, which “fosters competition rather than collaboration.” Prothrow-Stith advocates for three stages of prevention of violence: primary prevention, secondary prevention (or early intervention), and tertiary prevention (or treatment and rehabilitation). Primary prevention would be directed toward dealing with the public’s attitudes toward violence, whereas secondary prevention could focus on individuals who are considered to be at high risk of engaging in or being victimized by violence, and educating them in nonviolent methods of resolving disputes or displaying competence and power. Tertiary prevention would concentrate on reducing the negative consequences of a particular event after it has occurred, or on trying to find ways to use the event to reduce the likelihood of similar incidents occurring in the future. She explains. “Thus, one might think of improved trauma care, on the one hand, and increased efforts to rehabilitate or incapacitate violent offenders, on the other hand, as tertiary prevention instruments in the control of or the response to violence.” These models of violence prevention, Prothrow-Stith states, “can be very useful when applied specifically to the issue of interpersonal violence.” She adds, “Traditionally, public health responded by treating the violencerelated injury in the emergency setting. Today a new generation of committed health practitioners, community violence-prevention practitioners, social workers, and community activists have devised numerous intervention programs to serve medium- to high-risk (individuals).” She concludes, “The contributions made by public health professionals toward efforts to prevent violence have been tremendous. The continued application of public health strategies to the understanding and prevention of violence is essential to further progress. Also, the interface between public health and criminal justice must be continually explored to ensure complementary strategies and activities.” Despite decreasing crime rates recently, she adds, “Even with our lower national rates there is far too much preventable injury daily. The emphasis of the public health system will always be on prevention and the criminal justice system must place priority on aggressive responses to violence, but much possibility lies in enhancing the collaborative effort between both disciplines.”

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3.4 IS THERE A FORENSIC NURSE IN THE HOUSE? As private sector oversight entities and governmental agencies wrestle with the issue of identifying and caring for victims of violence, health care institutions scramble to do more—including meeting numerous patient-safety and quality-improvement mandates—with less, including fewer health care workers and smaller operational budgets. Many facilities cannot hire designated forensic personnel, and therefore depend on regular staff to compensate for this void. Physicians are dedicated, well-meaning individuals who are spread as thin as other health care professionals. Some are more aware of issues of IPV than others, but they are still in the minority. Many forensic nurses say that is precisely why they can provide essential forensic services when other health care providers can’t or won’t. On occasion, victims have verbalized their desire that physicians pay attention to issues such as IPV. Zink et al. (2004) undertook a study to understand how women who are victims of intimate-partner violence want physicians to manage these abusive relationships in the health care setting. Thirty-two mothers in IPV shelters or support groups in southwestern Ohio were interviewed to explore their abuse experiences and health care encounters retrospectively. The researchers discovered that participants believed physicians should screen women for IPV both on a routine basis and when symptoms indicating possible abuse are present, even if the victim does not disclose the abuse. They add that screening is an important tool to capture those women early in the process of victimization. When a victim does not recognize her relationship as abusive, participants recommended that physicians raise the issue by asking, but they also warned that doing more might alienate the victim. Participants also encouraged physicians to explore clues that victims might give about the abuse. The researchers discovered that in later contemplation, victims are willing to disclose the abuse and are open to exploring options. Physicians were encouraged to affirm the abuse, know local resources for IPV victims, make appropriate referrals, educate victims about how the abuse affects their health, and document the abuse. Participants identified a variety of internal and external factors that had affected their processes. In hindsight, IPV victims recommended desired actions from physicians that could help them during early stages of coming to terms with their abusive relationships. According to the researchers, in the primary care environment, 11 percent to 22 percent of women are currently experiencing physical abuse. They also said that a number of studies have demonstrated that

Forensic Nursing

IPV affects the physical and mental health of victims and of children who witness it. Rhodes and Levinson (2003) and Lapidus et al. (2002) as well as the Institute of Medicine report, Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence (National Academies Press, 2002), state that physicians will continue to see both genders who are abused and that the early recognition of abuse might influence the outcomes of care. The literature points to the fact that physicians are not screening for IPV as they should; according to Hamberger et al. (1992), the reported barriers to screening include time constraints, discomfort with the subject, fear of offending the patient, frustration with patient’s denial, lack of skills and resources to manage IPV, and the fear of opening “Pandora’s box.” Because physicians generally cannot tell which patients are in abusive relationships unless there are warning signs or diagnoses (illnesses frequently found in patients with IPV) or an abusive interaction between the patient and his or her partner is observed, guidelines recommend routine screening for IPV. The researchers said that some participants did not understand why they were asked about abuse, and others who were screened by physicians appreciated being asked. Many who had not been screened wished that they had been. Once participants began to acknowledge the abuse, they also began to have expectations about how physicians should react to what they learned, the researchers discovered. They identified four relevant patient expectations of health care providers: affirm that the abuse is real, know and inform victims about local IPV resources, educate victims about the effects of the abuse on themselves and their children, and document injuries in the medical record. The researchers also discovered that patients wanted physicians to affirm or validate that their relationships were abusive, and that no one, no matter what they did, deserved to be abused; that most women wanted their physicians to address the abuse and to know about IPV resources; and that they wanted to know health care providers were documenting information in their medical records for legal purposes.

REFERENCES Bell, K., & Benak, L D. Forensic nursing: The fastest growing discipline of nursing for the 21st century. Available online at: www.iafn.org. 2000. Hamberger, L., Saunders, D., & Hovey, M. Prevalence of domestic violence in community practice and rate of physician inquiry. Arch Fam Med. 24, 283–287, 1992. Joint Commission on Accreditation of Health care Organizations (JCAHO). Joint Commission 2000 Hospital Accreditation Standards. Oakbrook Terrace, IL. 2004.

The Mandate for Forensic Nursing

Lapidus, G., Cooke, M. B., Gelven, E., Sherman, K., Duncan, M., & Banco, L. A statewide survey of domestic violence screening behaviors among pediatricians and family physicians. Arch Pediatr Adolesc Med. 156, 332–336, 2002. Lynch, V. A. Clinical forensic nursing: A new perspective in the management of crime victims from trauma to trial. Critical Care Nursing Clinics of North America. 7, 3, 489–507, 1995. Lynch, V. A. Clinical Forensic Nursing: A New Perspective in Trauma. Collins: Bearhawk Consulting Group. 1997. Prothrow-Stith, D. Strengthening the collaboration between public health and criminal justice to prevent violence. J Law, Med Ethics. 1, 32, 82, 2004. Rhodes, K. V., & Levinson, W. Interventions for intimate partner violence against women: Clinical applications. JAMA. 289, 601–605, 2003. Sullivan, M. K. Opportunities and challenges in forensic nursing. In V. A. Lynch, Ed., Forensic Nursing in the Hospital Setting. New York: Elsevier. In press. Zink, T., Elder, N., Jacobson, J., & Klostermann, B. Medical management of intimate partner violence considering the stages of change: Precontemplation and contemplation. Ann Fam Med. 2, 231–239, 2004.

RECOMMENDED READINGS American Medical Association (AMA). American Medical Association Diagnostic and Treatment Guidelines for Domestic Violence. Arch Fam Med. 1, 39–47, 1992. Campbell, J. C. Health consequences of intimate partner violence. The Lancet. 359, 1331–1336, 2002. Campbell, J. C., Jones, A. S., & Dienemann, J., et. al. Intimate partner violence and physical health consequences. Arch Intern Med. 162, 1157–1163, 2002. Coker, A. L., Smith, P. H., Bethea, L., King, M. R., & McKeown, R. E. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med. 9, 451–457, 2000. Dienemann, J., Boyle, E., Baker, D., Resnick, W., Wiederhoen, N., & Campbell, J. C. Intimate partner abuse among women diagnosed with depression. Iss Mental Health Nurs. 21, 499–513, 2000. Drossman, D. A., Lesserman, J., Rachman, G., Zhiming, L., Gluck, H., & Toomey, T. C. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med. 113, 828, 1990.

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Edleson, J. L. Children’s witnessing of adult domestic violence. J Interpers Violence. 14, 839–870, 1999. Elliot, B., & Johnson, M. Domestic violence in a primary care setting: Patterns and prevalence. Arch Fam Med. 4, 113–119, 1995. Gin, N. E., Rucker, L., Frayne, S., Cygan, R., & Habbell, F. A. Prevalence of intimate partner violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med. 6, 317–322, 1991. Kernic, M. A., Holt, V. L., Wolf, M. E., McKnight, B., Huebner, C. E., & Rivara, F. P. Academic and school health issues among children exposed to maternal intimate partner abuse. Arch Ped Adolesc Med. 156, 549–555, 2002. Kolbo, J. R., Blakely, E. H., & Engleman, D. Children who witness domestic violence: A review of empirical literature. J Interpers Violence. 11, 281–293, 1996. Koss, M. P., & Heslet, L. Somatic consequences of violence against women. Arch Fam Med. 1, 53–59, 1992. McFarlane, J., Parker, B., & Soeken, K. Physical abuse, smoking, and substance use during pregnancy: Prevalence, interrelationships and effect on birth weight. JOGNN. 25, 313–320, 1996. McNeal, C., & Amato, P. Parent’s marital violence: Long-term consequences for children. J Fam Issues. 19, 123–139, 1998. Plichta, S. B., & Falik, M. Prevalence of violence and its implications for women’s health. Women’s Health Issues. 11, 244–258, 2001. Rodriquez, M., Bauer, H., McLoughlin, E., & Grumbach, K. Screening and intervention for intimate partner abuse: Practice and attitudes of primary care physicians. JAMA. 282, 468–474, 1999. Sugg, N., & Inui, T. Primary care physicians response to domestic violence. JAMA. 267, 3157–3160, 1992. Sugg, N., Thompson, R., Thompson, D., Maiuro, R., & Rivara, F. Domestic violence and primary care. Arch Fam Med. 8, 301–306, 1999. Walker, E. A., Koss, M. P., & Katon, W. J. Medical sequelae of sexual and physical victimization of women: A pilot study. Women’s Health Issues. 5, 77–78, 1995. Wolak, J., & Finkelhor, D. Children exposed to partner violence. In J. Jasinski, & L. Williams, Eds., Partner Violence: A Comprehensive Review of 20 Years of Research (pp. 73–112). Thousand Oaks, CA: Sage. 1998. Zuckerman, B., Augustyn, M., Groves, B., & Parker, S. Silent victims revisited: The special case of domestic violence. Pediatrics. 96, 511–513, 1995.

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4 Forensic Issues in the Clinical Setting CONTENTS 4.1

The Emergency Department as the Forensic Portal of Health Care ...................................................................... 43 4.1.1 Understanding the ED Physician’s Viewpoint of the Medico-Legal Continuum ...................................... 43 4.1.2 Busy Doctors Make Way for Capable Nurses in the ED ........................................................................... 45 4.1.3 Nurses Under Fire in the ED ...................................................................................................................... 46 4.1.4 The Investigation of Trauma in the ED ...................................................................................................... 47 4.1.5 Recognition of Forensic Cases in the ED................................................................................................... 48 4.1.6 Evidence Documentation in the ED............................................................................................................ 50 4.2 Presentation of Specific Forensic Cases in the ED ................................................................................................ 51 4.2.1 ED Care of the Sexual Assault Victim........................................................................................................ 51 4.2.2 ED Care of the Child Abuse Victim ........................................................................................................... 52 4.2.3 ED Care of the Elder Abuse Victim............................................................................................................ 53 4.3 The Forensic Nursing Response.............................................................................................................................. 54 4.3.1 Across the Border: Forensic Nursing in Canadian EDs Still Coming of Age .......................................... 55 4.3.2 Other Realms of Forensic Practice ............................................................................................................. 56 4.4 Sudden, Suspicious, or Unexpected Death in the Health Care Environment ........................................................ 58 4.5 Health Care Serial Killers ....................................................................................................................................... 59 4.5.1 Forensic Nurses’ Role in Identifying Health Care Serial Killers............................................................... 66 4.5.2 The VA’s Response to Health Care Serial Killers ...................................................................................... 67 4.5.3 The VA Considers the Adoption of Forensic Nursing................................................................................ 71 4.5.4 The Role of the Clinical Forensic Nurse Examiner ................................................................................... 72 4.6 Quality Improvement and Risk Management ......................................................................................................... 75 4.7 Violence in the Health Care Environment .............................................................................................................. 75 References ......................................................................................................................................................................... 78 Recommended Readings ................................................................................................................................................... 78

4.1 THE EMERGENCY DEPARTMENT AS THE FORENSIC PORTAL OF HEALTH CARE The frontline of forensic nursing is considered by many to be the emergency department (ED), the portal through which many forensic cases first enter a health care facility. Whether individuals are brought in by first responders such as paramedics and escorted by law enforcement officers, or whether individuals present themselves to the ER of their own accord, one thing is certain: The actions of this department’s personnel are the first stop on the medico-legal continuum.

4.1.1 UNDERSTANDING THE ED PHYSICIAN’S VIEWPOINT OF THE MEDICO-LEGAL CONTINUUM One of the most common forensic cases presenting to the ED is the sexual assault victim. Michael L. Weaver, MD,

FACEP, in his discussion of “Optimizing Physician/Nurse Role in the Criminal Justice System,” at the September 1999 National Non-Stranger Sexual Assault Symposium, further established the health care provider’s role as that of a “forensic clinician.” Weaver says, “This role is not only part of the criminal justice system, but is part of a communitywide multidisciplinary response to the issue of sexual assault and abuse. That role can therefore only be optimized if the entire community is working together.” A coordinated community response, according to Weaver, integrates the sexual assault response team (SART) with representatives from the community, forensic nurses, crime labs, law enforcement, prosecutors, hospitals, and social services, and together, protocols and outcomes can be developed. This model is particularly essential, Weaver says, knowing that not every hospital employs health care providers with specific forensic knowledge. Weaver says, “When and where patients are to be examined, chain-of-custody procedures, time limits for the 43

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evidentiary exam, who should take photographs, what type of camera, and the use of partial kits, are additional issues that impact the quality and consistency of the patient’s case.” He touches on a number of issues related to forensic cases, pointing to the varying levels of service that victims will encounter at health care institutions. He says: The importance of advocates in the criminal justice system meeting with forensic clinicians is exemplified by differences between various community hospitals. Standard protocol dictates that sexual assault victims are offered the “morning after pill.” However, in Catholic hospitals physicians are not allowed to prescribe this treatment. Hence, a community plan with alternatives for patients at those hospitals should be identified. Variation between forensic clinicians will also have a dramatic effect on the overall quality of the sexual assault case and may lead to patient re-victimization. Some communities are fortunate to have strong physician and nurse sexual assault advocates. Protocols that mandate examinations be performed by board-certified emergency physicians, sexual assault nurse examiners (SANEs), or other forensic examiners have already been developed. Unfortunately in some university teaching hospitals, the examination of the sexual assault patient may be relegated to a physician with minimal clinical experience (e.g., the intern that has just graduated from medical school). The OB-GYN, family medicine, or emergency medicine intern typically has little orientation and is not well supervised in this complicated medico-legal arena. The intern’s patients are usually forced to wait extended periods of time, evidence collection is frequently inadequate and the desire to compassionately care for these patients is highly variable. This may result in the degradation of crucial data, inadmissible evidence, or a patient that is emotionally re-traumatized. These concerns make it essential that a community standard be developed. A leading community organization with forensic clinician members has the additional benefit of allowing important public political pressures to be utilized for building consensus in the management of sexual assault cases.

Prior to a medico-legal case going to trial, Weaver says: It is important for advocates of the criminal justice system to understand that forensic clinicians may have apprehensions toward participating in sexual assault cases. Negative feelings many physicians and nurses have surrounding care for sexual assault patients are largely due to concerns about future interactions with the criminal justice system. Perceived abuses of power, disrespect, and fear of the courtroom have significant impact on their cooperation.

Weaver enumerates many forensic clinicians’ concerns when he says:

A major clinical issue is that months or years may have passed since the sexual assault evaluation. Thus, the clinician’s memory of important details, such as the patient’s demeanor, may have faded. Additionally a clinician may be uncomfortable because their hospital practice sees less than 50 sexually assaulted patients per year. Since sexual assault examination responsibilities are frequently rotated, forensic clinicians may ultimately examine one or two patients yearly. Typically less than 20 percent of cases actually go to trial. Therefore, it is unlikely to find a clinician that is not apprehensive about testifying in a sexual assault case. Clinical forensic examinations are usually not taught in medical or nursing school and there are few didactic postgraduate opportunities to learn. In essence, the sexual assault prosecutor who works in this area routinely must understand that in many instances, they may be more familiar with clinical issues than the average clinician.

Weaver explains that many clinicians feel inconvenienced by the criminal justice process. He says: Many prosecutors have their first contact with the forensic clinician indirectly through the subpoena. Health care workers usually perceive subpoenas as initial notification of a malpractice suit. Therefore their first response is full of negative emotions. After realizing that they are not personally being sued, the next emotion is frustration toward last-minute notification to appear in court. This initial encounter between the forensic clinician and the prosecutor damages a potential collegial relationship. Frequently, the forensic clinician views the subpoena as one professional being empowered over another, and the spirit of cooperation is quickly diminished. Additionally, most hospital physicians and nurses have fixed schedules, four to eight weeks in advance, and the ability to find replacements is very difficult. Last-minute notification may force them to work back-to-back shifts, or worse, work a night shift just prior to trial. In many instances the result is a hostile witness, who hasn’t properly reviewed the record, is not aware of the pivotal points of the case, and isn’t able to quote relevant literature that would be helpful to the prosecution.

In an attempt to resolve these and other related clinical and professional issues, Weaver suggests that a basic pretrial checklist should be developed. Citing work by KeenPayne (1998), Weaver offers a list of things that can help prosecutors and forensic clinicians collaborate in a more efficient manner. Regarding initial forensic clinician contact, Weaver suggests it should be arranged at least one month prior to the trial date, and that subpoenas should be avoided if possible. For the formal case review, the meeting should be scheduled at least two weeks prior to trial, avoiding an on-duty or an end-of-shift time frame. The case review should include a review of the health care institution’s rape kit, use of toluidine blue dye or colposcopy, chain of evidence, and routine laboratory process,

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and a review of the specifics of the case. Weaver suggests prosecutors evaluate the forensic clinician’s qualifications to serve as a fact or expert witness, reviewing the individual’s previous trial experience, professional training, certifications, and publications, and discussing the limits of the professional’s clinical expertise. Weaver also suggests that the prosecutor provide written guidelines for effective testimony including courtroom etiquette, direct and crossexamination procedures, and legal implications of terminology such as probable versus possible, as well as relevant literature for review. In the trial phase, Weaver says, “Trials are naturally unpredictable; therefore, every effort should be made to minimize variables that may diminish a successful outcome.” Following the trial, Weaver adds, “The posttrial phase is most important in influencing future care and community outcomes. Clinicians and nonclinicians need to be educated as to what is occurring in their community and share lessons learned . . . In a typical continuous quality improvement process, benchmarks should be established and data tracked to gain necessary feedback, maintain quality, and improve outcomes.”

4.1.2 BUSY DOCTORS MAKE WAY NURSES IN THE ED

FOR

CAPABLE

Chapter 1 discussed the concepts of clinical forensic medicine and its role in the emergency department. Smock (1994) states that a patient’s emergency medical evaluation must be detailed and the documentation comprehensive. He writes, “Comprehensive documentation ideally contains all three components: narrative, diagrammatic, and photographic. The failure to document a number of clinical findings comprehensively may have far-ranging consequences for a patient, an accused suspect, and, potentially, the treating physician.” Carmona and Prince (1989) reviewed 100 charts of patients who presented to the ED of a level-one trauma center in California; they found poor, improper, or inadequate documentation in 70 percent of cases, and in 38 percent of cases, potential evidence was improperly secured or documented, or inadvertently discarded. Smock comments, “The forensically untrained emergency physician may easily overlook and inadvertently destroy evidence, both gross and trace, in the course of providing patient care. He may misinterpret physical injuries and evidence, and form an inaccurate opinion as to their cause.” Massachusetts CFN specialist Georgia Pasqualone, MSN, MSFS, RN, CEN, DABFN, who says she has collaborated with Smock on a number of projects, understands the pressures placed on ED physicians and identifies with Smock’s call to forensic action: He’s one of my heroes. I firmly believe that every single physician who has any plans of going into emergency

medicine needs to be familiar with the concepts of clinical forensic medicine as so ably outlined by Bill Smock. For example, many ED personnel don’t know enough about clinical forensic medicine as they should, and run the risk of misnaming entrance and exit wounds, for example. Worse yet is to have them not recognize that something was evidence when it truly is, and they don’t collect it. I think it points to a need for clinical forensic personnel in every health care institution.

One of the assumptions of forensic nursing is that it not only provides medico-legal expertise, but also frees up physicians who are more interested in life-saving interventions than they are in following forensic protocol and going to court. “As nurses, we’re the first ones to handle the clothes, the first ones the patient talks to, we’re a nonthreatening entity, people will share with us a lot more than they are going to share with the busy doctor,” asserts Canadian forensic nurse Linda McCracken, RN. She explains that physicians can’t do it all or know it all, nor should they, especially when a capable, specially trained nurse is on the scene. “Physicians are going to burn out and they are not going to be able to do it all,” she says. However, from a clinical accuracy point of view, McCracken says physicians should learn from nurses who immerse themselves in forensic protocol: Physicians still document gunshot wounds as “entrance” and “exit” and I tell them, “You shouldn’t be saying that.” Most want to know why, and that’s a good sign. The trauma services director at our facility asked me to present my living forensics lecture to trauma rounds, to the heads of all the departments of trauma services. I was able to share with them that they shouldn’t be writing “entrance/exit” unless they are certified forensic pathologists. Instead, they should be writing “wound No. 1,” “wound No. 2.” I tell them, “Don’t make assumptions, and watch what you are charting.”

McCracken says she tries to keep up with the tenets of clinical forensic medicine to share with physicians and nurses: If you have what appears to be a sharp-trauma injury, maybe some type of knife wound, a doctor might chart, “Patient has a 2-cm laceration to the right side of the chest.” In actuality, that’s not a laceration, that’s a stab wound. A laceration is from blunt trauma. Health care personnel must change their language, but often they don’t. They continue to use the word “laceration” whether the wound is a cut, an incised wound, or a defense wound. Just write “cut.” How easy is that? I don’t think, from the medical standpoint, physicians have had any real training in forensic principles, let alone extended forensic practice.

Lynch (1995) writes:

46

Forensic Nursing

These cases are generally reported from the hospital emergency department. One reason that trauma care is of concern is that for all the reported crimes of human violence, there may be three times as many unreported crimes. Failure by health care providers to recognize the subtle signs and symptoms of abuse and neglect in the early warning stages, and failure to report to an investigating agency, can contribute to further injury or death . . . Trauma nurses perform an important role in the investigation of crime and the legal process in terms of victims of violence, both living and deceased. For example, questions related to trauma that may be of later relevance in a court of law may remain unanswered because of an emergency department nurse’s ignorance of forensic issues. Frequently, cases are won or lost based on the handling of evidence. If health care professionals fail to incorporate forensic guidelines, misinterpretation or omission of evidence may result in a miscarriage of justice. Clinical forensic nursing is designed to provide a solution to medico-legal-related problems in trauma departments. In addition to medico-legal issues, sensitivity to victims and families has historically been an exclusive concern of victim advocates from the perspective of basic human rights. As a patient advocate, it is a concern for the clinical forensic nurse.

Because the majority of victims of violence and trauma are seen in the ED, nursing personnel must be trained in the proper recognition, collection, documentation, and preservation of forensic evidence. From a bloodied shirt to hands bearing gunshot residue, ED personnel should be well versed in identifying and protecting evidence that is vulnerable to the care-giving process and could be otherwise lost forever. The difference in the way forensic evidence is recognized and handled, or tossed aside, forensic nurses emphasize, could be a miscarriage of justice. Even as nurses continue to observe proper forensic protocol, there is still some hesitance on the part of nurses regarding where clinical intervention ends and forensic protocol begins. The answer, experts say, is that they overlap whenever and wherever possible, although medical intervention always takes precedence. McCracken says that although this topic is starting to get more exposure in the nursing and medical literature, it might not be an automatic response. “Awareness of forensic protocol has certainly been helped by shows like CSI: Crime Scene Investigation, as more medical personnel are hopping onto the bandwagon,” McCracken says: Forensic science as it relates to nursing and health care is a hot topic right now. People hear all the time that they should try not to cut through bullet holes in clothing, etc., but people still do it. Those guilty of this most often are the paramedics, who also are the ones who throw things away. They get angry when I say to them, “This spine board is staying under the patient and you’re not getting

it back until it has been interpreted as evidence.” After all, the patient on the spine board was a naked woman found under a bush, obviously assaulted and injured. She was intubated and going into the ICU. I tell them, “We’re wrapping that spine board in a sheet and it’s going to the police.” Other times, medical personnel will recognize a wound as a potential gunshot wound or stab wound; they’re thinking about not cutting through a hole in the shirt, but then they get careless and throw it in the garbage. I ask them, “Where’s the shirt?” and they say, “It’s in the garbage.” And I immediately tell them, “Well, let’s go get it.” A law enforcement officer accompanies them and they retrieve the shirt out of the garbage. So not only must nurses and other ED personnel know the right protocol, pre-hospital personnel should know it, too. We can educate people by word of mouth, by modeling behavior, by in-services—the key is to keep spreading the word about the importance of proper evidence collection and preservation within the context of life-saving intervention.

4.1.3 NURSES UNDER FIRE

IN THE

ED

From a medico-legal perspective, it is essential that health care facilities have clear policies and procedures pertaining to health care providers’ interaction with patients, particularly those who might be victims or perpetrators of violence. Lynch (1997) observes, “In the interests of maintaining the patient’s rights and safeguarding the public’s rights, ethical issues have been raised concerning the nurse’s treatment of victims in the clinical setting.” She adds, “Protecting the patient, whether victim or offender, is the primary concern of both the health care provider and the police officer in the advocacy and ministration of victims of violent crime.” A lack of medico-legal protocol for health care providers and members of law enforcement when they are within the health care environment might create contentious situations that ultimately are detrimental to all parties. For example, some courts have upheld hospitals’ rights to refuse to have patients photographed by the police even though it is in the patient’s best interest to have their injuries photo-documented. In another instance, a state supreme court ruled that an ER nurse should not have turned over clothing worn by a patient (and potential perpetrator) to police because the patient was not under arrest at the time. The police officer who had brought the suspect to the hospital took the clothes from the nurse and used them to obtain a warrant of arrest. The patient filed suit against the nurse and won. Lynch (1997) cautions nurses to understand important legal precedents. She writes, “When the patient is a criminal, ethical issues have been raised concerning the nurse’s treatment of the patient in the emergency department. Protecting the patient—whether offender or victim—is the primary concern of health care professionals and law enforcement. Crimes against human beings force the nurse to decide which obligations are due the patient and which

Forensic Issues in the Clinical Setting

47

to law enforcement officers.” She adds, “Every hospital . . . eventually must address problems of conflict with law enforcement agencies regarding patients in legal custody. Contributing to the facilitation of interaction between police officers and the emergency department staff are policies that increase mutual understanding, define roles, and promote cooperation.”

4.1.4 THE INVESTIGATION

OF

TRAUMA

IN THE

ED

Lynch (1995) writes: Nurses have a unique opportunity to contribute to forensic science as they manage problems commonly encountered in trauma care. Law enforcement officers struggle to safeguard evidence during medical interventions, and resultant conflicts of priority may ensue. Medical-legal interface is critical among multidisciplinary teams investigating traumatic injuries, whether accidental, criminal, self-inflicted, or from unknown causes. Interface can be damaged, with serious consequences, when no forensic protocols exist. This occurs when police officers and hospital staff are not familiar with procedures that each is supposed to follow. The appointment of a designated hospital liaison to network with police and the coroner and/or medical examiner can provide a systematic approach to communication and coordination. This liaison should be knowledgeable of forensic concepts, legal responsibilities, and victims’ issues. The forensic clinical nurse specialist is prepared to fill this role ideally.

“A lot of forensic cases come in to the ER, so you are afforded many opportunities to learn what is forensic and what is not forensic,” says Bobbi Jo O’Neal, RN, BSN, F-ABMDI, deputy coroner in Charleston, South Carolina, who was an ER nurse early in her career. “You also have to interact with law enforcement officers because they are coming into the ER to see victims and suspects. The ER is the only place in the medical community where you will see these kinds of cases, and a wide variety of them.” O’Neal says she specifically came to the ER to get exposure to forensic cases and practices. “My interest in forensic cases was piqued early. I was an oncology nurse first, and began doing some part-time work with a hospice agency in Tennessee. I would have to call the coroner, after a patient died, to get permission to call the funeral home. I started asking questions of every person I encountered along the way. I realized that nurses could become involved and valuable in many types of forensic cases.” Although O’Neal might have had an early bent toward forensic practice, the ER in which she worked was lacking in proper forensic protocol. “When I was working in the ER, the sexual assault kits were still being done by the ER physicians, so the resident on call would do them. The nurse was really just a handmaiden during that process—I don’t think anyone thought of it as forensic nursing, even as late as 1996 or 1997. I don’t think there was an aware-

ness of forensic cases, even sexual assault cases, like there should have been.” As O’Neal was gaining a firmer grasp on the concepts of clinical forensic nursing, she would share them with her colleagues, but with mixed results: I think forensic protocols went over fairly well, but not for the reasons you might think. It went over well because they knew I was interested in doing (forensic cases), so if I was working that day, I would take care of those patients. If a sexual assault victim came in, they would say, “Give them to Bobbi Jo!” I think that my colleagues’ awareness started to come about slowly; if they had questions, they now had someone who could perhaps answer them.

Even in the face of demonstrated success, acceptance was slow by her coworkers: The ER really wasn’t interested in a more structured protocol. The hospital I was a part of eventually had an OBGYN physician who was very interested in sexual assault, and she started to develop a team concept but it really didn’t involve nurses much; it had more to do with the OB-GYN residents. They wanted a number of nurses to volunteer to help with their program. I initially sat down with her and said, “I think the way we are going about this is probably not good,” because basically they were saying, “Nurse, just open the kit, this is all you need to do,” and there really wasn’t any training for the nurses on what they should do. Even in that effort, I felt there wasn’t a lot of support for the nurses.

O’Neal explains that funding for the sexual assault program came through the facility’s psychology division, which secured monies to examine how victims responded from a psychological standpoint: Since the funding came through them, the psych department headed up the program. The problem came when the research assistants would show up at the hospital to meet the victim; one of their goals was to make sure the victim filed a police report and went through the program to ensure that they became a part of the research project. There were times when the victims were pressured to press charges, because that’s how they got into the research project. Often, I would get there and the victim would not be cooperative, so sometimes I would have to say, “Everyone out of the room” so I could sit down with them one on one and say, “You don’t have to do anything; you can leave, but first, let me tell you the benefits of this program and why I am here.” Ninety-nine percent of the time, the victim went through the exam, we were able to get them prophylaxis if they needed it, and attend to their needs.

The program was fraught with politics, however, O’Neal says:

48

Forensic Nursing

Not too long after that, all of the nurses who were part of the team resigned. They said, “By being a part of this program and how it was run, we felt we were re-victimizing them, which is not what we want to do, and we felt we had lost sight of the purpose of doing the forensic exam. Yes, we wanted to get them to counseling and all that stuff, but first and foremost, we are trying to do a forensic exam to gather the evidence that was needed so that prosecution could take place, and we hoped to do it in an atmosphere in which we wouldn’t add to their harm or distress. The nurses felt that wasn’t happening.”

4.1.5 RECOGNITION

OF

FORENSIC CASES

IN THE

ED

Pasqualone (2003) writes, “Recognition of forensic issues that accompany patients into the emergency department is nearly as important as the priorities in rendering lifesaving treatment.” Pasqualone’s research reveals the presence of at least 24 forensic categories among patients seen at a community hospital ED. She asserts that by identifying these categories and the numbers of patients within them, the resulting data will mandate the presence of a CNS in forensic nursing in the ED as well as on call to other departments of the hospital. “A CNS in forensic nursing should be established as an integral component of the ED health care staff,” Pasqualone adds: The establishment of forensic categories will further clarify the educational needs of the ED nursing staff. Nurses must be educated with regard to the forensic issues surrounding the victims of trauma and violent crime. If staffing is inadequate, the priorities of treatment may well outweigh the importance of recognizing, documenting and collecting evidence. If important evidence is destroyed and/or overlooked, a serious injustice could be rendered to the patient, suspect, or hospital.

Pasqualone says: A general lack of knowledge about forensic issues identifies a need for the categorization of this unique patient base. A systematic approach to the clarification and delineation of forensic categories is compulsory, should the need arise to provide evidence in a litigious situation. Concise, chronological identification and documentation of these evidentiary groupings is essential as a prerequisite of current and future ED nurses’ inevitable direct involvement in judicial proceedings. ED nurses’ attitudes and familiarities with the majority of forensic issues are, more often than not, limited to their initial dialogue with law enforcement personnel concerning the medical condition of a patient. ED nursing personnel must be aware at all times of the necessity to integrate the appropriate collection of any significant evidence, both demonstrative and testimonial, while providing care. This most assuredly can be accomplished in a proficient manner.

Pasqualone acquiesces that although life-saving interventions come first: The trail of evidence and the chain of custody are being destroyed far too many times during the flurry of saving a life. It later appears in court that justice is not being served, that the guilty are escaping punishment, and that victims are being victimized once again. Mistakes in forensic cases exist, made and then compounded by ignorance, incompetence, or indifference. By initiating a conscientious system of recognizing, assessing, collecting, documenting, photo documenting, and reporting, ED nurses can assist their patients, their local police departments, and the entire legal community by maintaining chain of custody, being aware of important issues, and detailing all evidence in the medical record.

To facilitate development of the forensic categories, Pasqualone (1998, 2003) examined the records of patients admitted through the ED of a small community hospital located just outside of a major metropolitan city in eastern Massachusetts. The ED sees approximately 22,500 patients annually. The categorization system was developed from a retrospective study of ED medical records. The population studied consisted of every person (N = 3,436) admitted to the ED during a 60-day period. Approximately 914 patients (27 percent) qualified as forensic cases. The top categories were occupation-related injuries, 289 (8.41 percent); transportation injuries, 193 (5.62 percent); substance abuse, 160 (4.66 percent); personal injury, 125 (3.64 percent); and forensic psych, 49 (1.43 percent). In addition, Pasqualone discovered that child abuse and neglect cases numbered 464 per year (2.06 percent), abuse of the disabled numbered 130 cases per year (0.58 percent), human and animal bites numbered 90 per year (.40 percent), elder abuse and neglect numbered 56 cases per year (.25 percent), assault and battery numbered 22 per year (.64 percent), domestic violence numbered 6 cases (.17 percent), sharp force injuries numbered 7 cases per year (.03 percent), clients in police custody and sexual assault each numbered 2 cases per year ( .06 percent), and firearm injuries consisted of 7 cases in three years (.01 percent). The categories of child, elder, and disabled abuse and neglect; human and animal bites; sharp force injuries; organ and tissue donation; burns; and firearm injuries were extrapolated from ED admissions and statistics of mandated reports taken over a one-year period. Although food and drug tampering, gang violence, and malpractice and negligence were not categories identified among the ED population during the study, Pasqualone reports that they are categories having the potential of occurrence at any time in any ED. Goll-McGee et al. (2003) emphasize that: Clinical forensic nursing has come of age as a means of coping with the resultant increased complexity of nursing

Forensic Issues in the Clinical Setting

practice, society and the law. A living forensic population, “survivors of criminal or liability-related injuries that result in an investigation by a legal agency,” is being recognized by health care professionals in varied clinical practice environments, especially in the ED. In fact, personnel frequently interface with forensic cases and therefore have the greatest potential for evaluating the associated forensic elements.

Goll-McGee et al. add, “As nurses on the front line begin to ponder the presence of a forensic patient population they will look to address their needs. As our knowledge base expands, professionals themselves develop and nursing paradigms shift.” Smock (1994) says that continued attention to these types of cases and the use of this forensic nursing process could make an important contribution to safeguarding the legal rights of patients and the community and nurture clinical forensic nursing, a developing nursing specialty, within practice environments. Once a forensic patient is identified, the nurse engages in clinical practice encompassing evidence collection, documentation, and intervention. According to Mund (1996), physical evidence is anything that has been “used, left, removed, altered or contaminated during the commission of a crime by either the suspect or victim.” Forensic nurses working in the ED can look to the position statement from the Emergency Nurses Association (ENA) for guidance on the specifics of forensic evidence collection. According to the ENA: Victims of sexual assault, child maltreatment, elder abuse and other violent incidents are often brought to the emergency department (ED) for care, treatment, and evidence collection. Evidence can, during the course of the ED evaluation, become lost by being cut through, brushed away, or overlooked. The performance of forensic procedures is a component of emergency nursing practice. The emergency nurse identifies the need for forensic evidence collection, and for collecting and preserving the evidence. These procedures are a part of the scientific investigation, evidence collection and preservation, analysis, prevention and treatment of trauma and/or death-related medicallegal issues. The emergency nurse caring for a victim of crime also is responsible for accurate documentation and the ability to perform the duties of a witness during court proceedings. The nurse also may be requested to function as an expert witness in medical-legal investigations, including depositions and courtroom testimony.

The ENA’s position statement on evidence collection says: ENA believes that it is the emergency nurse’s role not only to provide physical and emotional care to patients, but also to help preserve the evidence collected in the emergency department. ENA supports collaboration with

49

emergency physicians, social service, and law enforcement personnel to develop guidelines for forensic evidence collection and documentation in the emergency care setting. ENA encourages emergency nurses to become familiar with the concepts and skills of evidence collection, photographic and written documentation, as well as testifying in legal proceedings.

The ENA emphasizes, “An emergency nurse is often the first person a patient encounters after an incident of violence. Emergency nurses should have the skills needed for evidence collection and preservation. Emergency nurses are skilled in providing comprehensive care and treatment of the patient as well as in maintaining the chain of custody and appropriate documentation.” Numerous experts have addressed the importance of proper identification of forensic patients, as well as appropriate assessment and documentation. Goll-McGee et al. (2003) write, “The development of protocols for collecting available evidence may assist in assuring that collection is performed appropriately.” Goll-McGee et al. add, “Proper collection of evidence is imperative to avoid the compromise of its integrity.” Hoyt (1999) states, “Preservation of evidence in the clinical setting requires planning, attention to detail, and the guidance of agency policies and procedures.” George et al. (1997) write, “In the duty to document . . . it is almost as important to keep extraneous material out of the medical record as it is to be sure to include pertinent information.” GollMcGee et al. (2003) add, “In many situations, important information . . . which may not be required for patient care is nonetheless vital to later investigation and requires the patient’s consent to ensure that collection of the evidence will not amount to an illegal search (or perhaps malpractice).” Smock et al. (1994) state, “Thorough, objective documentation of ED evaluation and treatment of patients who present with complaints suggesting potential litigation and/or criminal activity is critical. Meticulous documentation provides evidence that something is done or not done, exists or doesn’t exist, it provides evidence for the client, protection for the nurse and testimony for the court.” Perhaps most important, experts point to the need for a high index of suspicion in the ED. Winfrey and Smith (1999) state, “Intuition . . . gives the forensically educated nurse permission to trust and to act upon his or her suspicions.” Goll-McGee (1999) writes, “Non-physical evidence collection suggests the use of an index of suspicion to uncover the how and why of their mechanisms of injury. This effort involves an assessment of psychosocial history, separating the injuries from the story and asking hard questions. It looks for inconsistencies in clinical presentations.”

50

Forensic Nursing

4.1.6 EVIDENCE DOCUMENTATION

IN THE

ED

One of the most important forensic steps a nurse in the ED can take is the performance of thorough photo-documentation of a patient’s injuries; however, many nurses wrestle with patient privacy restrictions. McCracken says she struggles with Canada’s privacy laws, the same way many nurses grapple with federal Health Insurance Portability and Accountability Act (HIPAA) compliance and state privacy laws in the United States. “The big issue related to evidence collection and recognition of injury and assessment in the ED is photo documentation,” she says: Here, it is considered to be infringement of an individual’s privacy, and the big question is, are you getting patient consent. But nurses say, “How will I get consent if the patient is unconscious?” At our facility, the photography consent form doesn’t refer to documentation of suspicious injuries. I have told the people in legal services who drafted the consent form that it needs to be changed. I have gotten the support of our trauma services who say they love the pictures I take—not only does it help them from a medical-legal standpoint, but later on, if a case goes to court, those bruises are healed—but hey, I have Polaroid photos taped to the nurses’ notes so medical records won’t throw them away—they are good for 99 years. I encountered a lot of resistance from my managers when I said, “We need a Polaroid camera.” I told them a camera is better than marking an X on a body map. Over and over again, it’s proved that photographs save the day. There was a case where a patient died from her injuries, and when the chart was pulled, my photos were still in there. Hospital hierarchy is afraid of taking pictures of people.

Many ED nurses are unaware of forensic protocol and struggle with its implementation. Lynch says, “Emergency nurses become involved when a patient is admitted for trauma care as a result of suspicious injuries that may be crime-related or self-inflicted. These patients require nurses to be aware of the manner in which the assessment of injury, forensic evidence, and critical data are documented with law enforcement and crime scene officers.” She adds: The problem of gathering evidence in the emergency department is compounded by failure to develop and implement forensic guidelines for nurses. A classic problem is the lack of an acceptable method for preserving evidence from crimes that are discovered long after the patient has been admitted or has died. This situation is further complicated when the forensic pathologist becomes involved after the destruction of the evidence, or the condition of the body has been altered by surgical intervention. Hospital emergency departments are regularly in contact with essential evidence in criminal cases.

The evidence collection process is addressed throughout this text, but a quick primer for ED nurses is appropriate. The types of evidence most commonly encountered by ED nurses include clothing, bullets, blood stains, hairs, fibers, and small pieces of material such as fragments of metal, glass, paint, and wood. Trace and physical evidence are used to establish the facts of a crime. Lynch says: If, however, proper precautions are not taken to ensure an unaltered condition when collecting specimens, the forensic examination is compromised. When crime victims are treated by emergency department staff, forensic evidence is often lost because medical personnel are not aware of its presence or potential value. Problems in gathering evidence in the emergency department, surgical suite, or any department in the hospital are not restricted to the failure to recognize or collect forensic evidence; often, there is failure to properly preserve fragile or perishable evidence. Documentation must reflect the accurate identification, description, and security of medico-legal evidence.

Lynch (1995) acknowledges the dual responsibility of providing medical care and following medico-legal protocol in the ED. She writes, “The dilemma of gathering evidence in the emergency department is a serious cause of concern in traumatic injury patients.” She adds that ED staff should recognize the importance of recovering possible items of evidence in a legally acceptable manner in medico-legal cases, defined as a treatment situation with legal implications, such as suspicious deaths or crimerelated injuries, and accidents that might trigger some form of civil or criminal litigation. Lynch states that it is imperative for ED staff to recognize and preserve vital fragments of trace evidence through careful handling of the patient’s clothing and personal property. She writes, “This is one of the most important actions nurses provide to aid the investigation process. Clothing worn at the time of the incident may contain trace evidence useful in linking the victim with the assailant or crime scene.” She adds, “Careful examination of defects in clothes can be compared to wounds of the victim, and often clothes provide insight as to the type of weapon or wounding instrument used. Clothing should be checked for blood, semen, gunshot residue, or trace materials such as hair or fibers.” The clothing and the trace evidence should be properly photo-documented, diagrammed, collected, and preserved. Lynch (1995, 1997) writes, “Documentation of the condition of the patient’s clothing should be carefully noted. Color, type, unusual markings, and tears or other damages should be recorded. Occasionally, fibers or foreign debris from the crime scene on the victim’s clothing may be transferred to the vehicle or assailant. Clothing is often the first circumstantial evidence that may help to identify a missing person or collaborate an eyewitness statement.” Clothing should be carefully removed to protect any foreign fragments adhering to them, and they should not be shaken.

Forensic Issues in the Clinical Setting

“Clothing is frequently cut away during resuscitation attempts and is subject to loss of both the article itself and/or evidentiary materials,” Lynch explains: The cutting of clothing is unavoidable in many life-threatening situations and is necessary to provide immediate access to treatment sites. When this occurs, try to avoid cutting through tears, rips, and holes that may have resulted from the weapon or the assault. Clothing should never be discarded or thrown on the floor, as this can result in cross-contamination of trace evidence with debris from the treatment environment.

She adds that due to time constraints during life-saving intervention, a clean, white sheet can be placed on an empty trauma table, Mayo stand, or on the floor in the corner of the room for clothing to be placed until time permits for effective packaging. If a victim is able to remove his or her clothes, this should be done standing on a clean sheet or a large sheet of paper to collect any microscopic evidence that might become dislodged during removal. The sheet should be packaged in a separate paper bag for transfer to the crime laboratory. Regarding the preservation of evidence collected in the ED, moist clothing should be hung to dry in a secure location. Clean white paper should be placed over stains to avoid cross-contamination, and each item of clothing should be stored in separate paper bags, not plastic bags. Plastic bags are inappropriate because there is a tendency for condensation to accumulate, resulting in a degradation of the integrity of the evidence. Each bag should be sealed and clearly marked with the date, time, and signature or initials of the individual doing the sealing. Health care professionals in the ED must maintain secure custody of the clothing and trace evidence until it is handed over to law enforcement. A chain of custody commences with the individual collecting the evidence; this person maintains custody of evidentiary material. The chain of custody should be defined in the health care institution’s forensic protocol and generally requires a form of written documentation. Rules of evidence require a chain of custody for each item recovered from the patient, including trace and physical evidence, laboratory specimens of blood and body fluids, clothing, and personal articles. Lynch writes, “The integrity of every specimen or piece of evidence seized must be ensured to protect the admissibility in a court of law. Failure to maintain the chain of custody renders potentially important evidence worthless if lost, damaged, or unaccountable from the hands of the nurse to the police officer.”

4.2 PRESENTATION OF SPECIFIC FORENSIC CASES IN THE ED Issues of sexual assault, child abuse, and elder abuse are discussed thoroughly later in this text; however, it is appro-

51

priate to set the stage by discussing the treatment of these victims in the ED as further proof of the need for properly trained forensic health care personnel.

4.2.1 ED CARE

OF THE

SEXUAL ASSAULT VICTIM

Carr (2001) asserts that victims of sexual assault deserve competent, compassionate medical evaluation, but that many ED physicians believe they are not adequately trained or prepared to perform the time-consuming, intricate evidentiary examinations required. She writes: A loud, busy emergency department is a hostile type of environment for victims. Doctors and nurses pulled in many directions may be perceived as being gruff and uncaring to the victim. These patients may leave before they receive medical care, and because of this poor introduction to the system may drop out. They fail to obtain needed emotional counseling and justice is not pursued. A badly performed medical exam that is not well documented is of little value. Chain of custody for forensic evidence must be maintained or it will be worthless from a legal standpoint. Concerns regarding pregnancy, sexually transmitted infections, safety and follow up care need to be addressed before the patient is discharged.

Carr points to the burgeoning number of SANEs and SARTs, but is cautious about these programs, no surprise to forensic nurses who are well aware of physicians’ skeptical—and to a large degree inaccurate—perspectives of their performance. Carr writes: Several areas around the country have formed nurse examiner programs to perform the sexual assault exam. These programs are staffed by nurses specifically trained in performing the sexual assault exam. They are closely associated with EDs so that if the patient has significant injuries or medical issues, a physician is nearby. These programs seem to be the answer to all the problems that arise in the ED when a victim of sexual assault presents. There are however some problems with the programs. A review of the SANE programs found an almost ten-fold difference in the amount of education received by nurses prior to performing this service. One of the greatest problems is that only a few programs keep track of statistics. All aspects of the sexual assault exam need to be looked at critically in order to achieve a format that is both useful for prosecution and not too unpleasant for the victim. SANE programs began in the later 1970s and have doubled in numbers in the last five years. Hopefully the programs will soon become more standardized and data analyzed in order to make valid decisions about the utility of many aspects of this exam.

Carr asserts that there is a paucity of evidence-based medicine to support the current management of the sexual

52

Forensic Nursing

assault victim and as a result, numerous controversies rage. Carr writes: Recently I heard a former president of ACEP tell a group at a conference that the history of a sexual assault victim should be kept to a minimum in order to avoid discrepancies between the victim’s story to the medical field and that to the police. Most programs feel that a well-documented medical history is needed for the evaluator to know the mindset of the victim during the assault that caused her to act as she did. The potential physical injuries are also gleaned from a good history. One of medicine’s main objectives in these exams is to determine if the physical findings are consistent with the history given by the victim.

Carr recommends that ED personnel not involve themselves in what she describes as a “he said, she said” telling of the traumatic event, but to document direct quotes from the victim, or “excited utterances” that indicate the patient’s state of mind during the assault. Carr writes, “Such statements can be used as testimony and are exempt from the hearsay rule because they are statements given for the purpose of medical diagnosis. Contradictions in victim statements are issues for attorneys. It is not wise for a physician with little legal training to try to decide what will be legal issues and consequences.” Carr acknowledges undiscerning health care professionals’ tendency to overlook minute forensic considerations as small as the trace evidence that might be residing in the nooks and crannies of a patient’s skin and clothing. Carr writes, “The physical exam needs to be carefully performed with attention to all findings including those that are typically of little medical concern. After ruling out significant injury we want to look for evidence that assists in identifying the assailant, provides proof of force or coercion, proves recent sexual contact and corroborates the victim’s story.” Bruises, redness, swelling, scratches, bites, or ligature marks must be documented in the medical record through a complete description, by drawing on an anatomic diagram, or by photographing the injured area. Carr says that perineal, anal, and pelvic exams can be performed with the aid of a colposcope, with or without an attached camera. Carr writes, “Programs providing service to sexually abused children find that photographing this area is very important. Many normal variants exist in children that may otherwise be interpreted as injuries. In adults the value of the colposcope in seeing injuries not well seen by general exam is well documented. But the interpretation of findings is only as good as the medical provider.” She says that the finding of micro-abrasions, redness, swelling, and bruising is of value when they corroborate the victim’s statements, and must be differentiated from those caused by consensual sex, tampon placement, or constipated stool. She writes, “So far,

there is only one study evaluating genital changes after consensual sex. In this small study it was determined that microtrauma can occur and it was seen with a colposcope. This microtrauma consisted of tiny broken blood vessels and micro-abrasions.” She continues, “There is also a study showing no evidence of trauma in two patients with semen present who also reported a sexual assault, suggesting that physical findings do not have to be present after a sexual assault.” Carr admits physicians’ discomfort in conducting examinations. “Properly obtaining forensic evidence can be distressing to the physician,” she acknowledges: We are not used to the role of investigator. In this instance, the crime scene is the body, with evidence inside and outside. It is important to keep in mind that the evidence we want to obtain is that of the assailant. This evidence will be washed away, wear away or degrade in a short time. Most feel after 48 hours there is little likelihood of obtaining evidence. Others feel 72 hours is a better time frame. It is not unreasonable to assume that as forensic testing becomes more sensitive we will be able to obtain evidence beyond 72 hours.

Carr explains that most programs obtain evidence from only those areas of the body the patient says were involved, whereas other programs believe it is necessary to obtain evidence from all orifices because the victim might be too traumatized to know what happened to him or her. Carr adds that specimens must be sealed and a record kept of the rape kit at all locations along the path; the kit can never be left unattended if it has not been sealed. Carr concludes, “The sexual assault exam continues to be a bane of emergency physicians. Many more studies need to be done in order to determine the areas of the exam that are beneficial to the patient from a medical standpoint and the areas that are useful in the legal process.”

4.2.2 ED CARE

OF THE

CHILD ABUSE VICTIM

Reece (2001) says that the most common injury seen in the ER is bruising. He explains that the keys to diagnosing these bruises as having been inflicted are location and patterns. Reece writes, “If they are on the posterior aspects of the body, on the sides of the face, the buttocks, the genitalia, the ears or the neck, or on the abdominal wall, they are more likely to be of abusive origin than accidental. The other key is pattern. Certain instruments are used in harsh discipline, and these leave characteristic marks.” Although clinicians are still debating the stages of bruise healing as markers for determining when an injury was sustained, clinicians agree that the presence of bruises in various stages of healing is also indicative of repetitive injuries. Reece writes:

Forensic Issues in the Clinical Setting

One word of caution about judging the ages of bruises by their color: the older literature contains misinformation about judging the ages of bruises on the basis of color. For example, older textbooks display a chart indicating that certain colors suggest certain ages. When this was studied recently, the conclusions of the authors were that there are too many variables to make definitive determination of the age of the bruise based on color. Rough estimates may be made, but it must be recognized that there is a range of error of two to four days. One of the more recent articles that is helpful in judging the origin of bruising was subtitled: “Those who don’t cruise rarely bruise.” In this study of bruising in various age groups it was found that bruises seen in nonambulatory children were more likely to have been inflicted than in children old enough to walk, a seemingly self-evident finding but one that is often forgotten when confronted with unexplained bruises.

Head injury in children is another common presentation to the ER. According to Reece: Head injury is the most common cause of mortality from child abuse and it is also the reason for most long term morbidity in survivors. Head injury can be the result of direct blows to the head by fists, feet, or objects, or by striking the child’s head against an object. In infants, shaking or shaking with impact are the most frequent mechanisms for producing signs and symptoms referable to the central nervous system. Injuries to the head cover a wide spectrum and so the resultant signs and symptoms are also quite variable. Smaller biomechanical forces lead to smaller injuries and milder symptoms.

According to Reece, head injuries can present the following symptoms: extreme fussiness, inconsolable crying, irritability, lethargy, hypotonia, disinclination to feed, vomiting, tachypnea, bradycardia, hypothermia, seizures, gaze preferences, unequal or unreactive pupils, stupor, coma, and death. Reece says that another common presentation in children that might be a sign of abuse is fractures. Distinguishing accidental from inflicted cases can be challenging. Reece writes: As in all abuse, the younger the age of the child with traumatic injuries, the more likely the etiology is abusive. Fractures in children under the age of 12 months are, in the majority of cases, abusive. Fractures in certain bones are highly correlated with abuse: posterior rib fractures, metaphyseal fractures, bilateral or multiple fractures, multiple fractures in various stages of healing, digital fractures, scapular fractures and complex skull fractures. The type of fracture, however, helps little in determining the etiology. Older literature suggested that spiral fractures were more often associated with abuse, but more recent studies have

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shown that this type of fracture only tells us about the mechanical forces involved in the production of the fracture, but not whether or not it was abusive. Certain fractures, such as a toddler’s fracture, clavicular fractures, simple skull fractures, and long bone fractures in older children are much more likely to be of accidental origin. When evaluating for the possibility of abuse, other medical conditions that can produce fractures, such as osteogenesis imperfecta or fractures through pathologic bones, must be considered and ruled out if appropriate.

4.2.3 ED CARE

OF THE

ELDER ABUSE VICTIM

In 1997, the American College of Emergency Physicians (ACEP) released a new practice guideline to address the presentation of elders to the ED. In a seven-year study of ED use by older victims of family violence, 182 physical elder abuse victims were identified, and 114 (62.6 percent) had been seen in an ED at least once during a five-year period surrounding initial identification of abuse. These 114 individuals accounted for 628 visits, 30.6 percent of which resulted in hospital admission. The patients in the study were primarily female (76.3 percent) and White (85.3 percent), with a mean age of 73.1 years. Adult sons were the abusers in 28.9 percent of cases, spouses in 26.8 percent of cases, and adult daughters in 21.6 percent of cases. Other abusers included grandchildren, other relatives, and friends. The most common weapon used was the body (punching, kicking, slapping), but knives, canes, furniture, and pipes also were described. Injury, including fractures, lacerations, and contusions, was the chief complaint. The study concluded that elder abuse victims have substantial interactions with EDs that frequently result in hospital admissions and that strategies to identify elder abuse in less acute settings would improve quality of life and likely result in substantial savings in health care expenditures. Another survey, “Elder Mistreatment: National Survey of Emergency Physicians,” was the first one to survey emergency physicians to determine the perceived magnitude of elder mistreatment, levels of physician awareness, and willingness to report suspected cases. It also sought to determine the barriers to reporting suspected cases of elder mistreatment and physician awareness of state elder abuse laws. Fifty-two percent of the more than 700 surveys completed by members of the ACEP described elder mistreatment as prevalent but less so than spouse or child abuse. Ninety-two percent of the physicians indicated their states did not have sufficient resources to meet the needs of elderly victims. Only 31 percent reported having a written protocol for reporting elder mistreatment. Physicians also were generally not familiar with applicable state laws and did not feel confident about identifying or reporting elderly victims of abuse or neglect. Until recently, research on domestic violence has been focused mainly on spouse and child abuse, and little attention has been

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Forensic Nursing

paid to the mistreatment of older people. The results of the survey highlight the need for greater training and continuing medical education focused related on elder abuse in the field of geriatric emergency medicine. Jones (1991) states that as many as half of the elderly patients who present in an ER will be admitted to hospitals, transported to skilled nursing homes, or placed in a protected environment for further diagnosis and treatment of their urgent care conditions. The other half will be released, and a significant number of them, because they live alone and have few family members or friends to assist them, are at risk of returning to the ER. Jones writes: A shortage of primary-care physicians, especially ones trained in geriatrics, in rural and low-income urban areas, seems to be one of the reasons why more elderly are going to ERs. Overloaded with patients, doctors often can’t find the time to advise the elderly on preventive measures, monitor their chronic conditions, or prescribe new medications before a crisis develops. And when one does, the doctor may not be reachable. In a recent Philadelphia study, nearly two-thirds of the seniors surveyed found their doctors to be inaccessible during a crisis because of irregular office hours or lack of a 24-hour answering service. Research shows that most older persons have good reason to go to emergency rooms when they do, because they have proportionately as many or more emergency and urgent care needs as other age groups. Unfortunately, most ER doctors and nurses receive little training in geriatrics. The needs of some elderly ER patients are different from those of younger ones and may not be met in the middle of ER crisis and confusion . . . Time pressures may limit the ER staff’s ability to take down comprehensive medical histories of an older person, (and) fully evaluate symptoms.

4.3 THE FORENSIC NURSING RESPONSE Pasqualone says: There is a need to place advanced practice forensic nurse clinical specialists into our hospitals, nursing homes, schools, criminal justice system and anywhere else in our communities where nurses can act as the liaisons between medicine and the law. Nurses will be prepared to enter into this new career field as medico-legal consultants for attorneys, insurance companies, law enforcement agencies, medical examiner and coroner systems, school departments, nursing home administrations and hospital EDs. Although the contemporary media has portrayed the forensic scientist as a death-investigating Quincy, able to solve a murder in less than an hour, one can now appreciate the comprehensive involvement of forensic nursing and its far-reaching influence with this science of the 21st century. The need for a greater consciousness on the part of all health care providers with regard to delivery of more

cost-efficient medical care cannot be emphasized enough. The forensic needs of the client, though, must not be jeopardized. Efficiency can be improved through a wellcoordinated intelligent process that improves performance without compromising quality. More efficient utilization of resources means more resources can be available for those in need.

Pasqualone advocates for a mobile system that facilities quick, efficient response to forensic cases. She explains: When interfacing with a forensic patient, the ED nurse must strive to utilize a logical approach and have an algorithmic method in place for the forensic nursing process. The nurse can then recognize, assess, collect, document, photo document, preserve and report, depending on the patient category. An ED forensic cart is one way of taking the initial guesswork out of “What do I do now?” The cart can be similar to those utilized by the ED for code situations. On it should be various sizes of clean paper bags for clothing; plastic containers for leaves, fibers, buttons, paint chips and the like; clean white paper for making bundles for the smallest hairs and fibers; sterile swabs; sterile water; evidence tape; felt-tip pens; labels; clean sheets; and file folders containing all mandated reporting forms. The state’s sexual assault evidence collection kit should also be included on the cart. A 35-mm camera or an instant camera system plus film should be available at all times to the ED personnel for photo documentation of injuries. If a hospital policy for chain of custody for film processing is in place, the 35-mm system can be utilized with peace of mind. Otherwise, instant photographs can be placed in the medical record immediately. There is both practicality and economy when utilizing the cart when caring for forensic patients. In-service education must be an ongoing process. Laws change and ED nurses must be kept informed of legislative ramifications of their care. Policies and procedures should be written and overhauled in order to manage the forensic populations properly. In fact, the study of forensic nursing should be integrated into the most basic of nursing educational processes. Evidence may present itself to paraprofessionals as easily as it is to the professional health care provider. If evidence is destroyed unknowingly, cases can be lost in the process.

Pasqualone says that hospitals should initiate a tracking mechanism for all forensic categories of patients. She explains that a facility that is unaware of the incidences of forensic situations “inhibits the gathering of valuable statistics, as well as deterring the process of addressing educational needs for all staff.” She adds: Registration personnel could potentially track forensic categories as they register into the ED; however, nursing staff should be making note of the categories as the

Forensic Issues in the Clinical Setting

patients are seen. By identifying forensic categories and the numbers of patients within these categories, the high percentage of forensic patients (27 percent) identifies a need for a forensic clinical nurse specialist in the ED setting. A CNS in forensic nursing should be established as an integral component of the staffing patterns in the ED.

Pasqualone believes that nurses and all ED staff should be educated about the forensic issues surrounding the victims of trauma and violent crime. “Categorization will lead to recognition; recognition will lead to adequate staffing; and adequate staffing will lead to a more complete preparedness and treatment for this unique population of patients,” she says. “If staffing and education are inadequate, the priorities of treatment may well outweigh the importance of recognizing, documenting, and collecting evidence. If important evidence is destroyed and/or overlooked, a serious injustice could be rendered to the patient, suspect, or hospital.” She continues: Our rapidly evolving health care environment necessitates a change in the way we practice nursing. Nurses aware of mandated reporting cases protect patients’ rights as well as maintaining patient safety. Forms should be completed correctly and expeditiously. Statistics should be recorded and this information could be utilized for greatly needed research on the cycle of violence and classification of patients. Nurses aware of the benefits of photo documentation can save their clients time and money within the judicial system due to the accuracy and supplemental recording of injuries. In addition, forensic nurse consultants can save hospitals time and litigation fees with their testimonial expertise. Knowledgeable nurses can truly decrease the number of lawsuits that are actually introduced into the court system. Nailing the evidence could potentially eliminate the need to go to trial. The application of forensic techniques is essential. The structure of the entire forensic nursing process is predicated on maintaining a certain state of mind—an investigative, interpretive, dogmatic search for the facts and the truth. The forensic nursing process, as an extension of the general nursing process, is being cultivated in an increasing number of EDs of health care facilities across the country.

4.3.1 ACROSS THE BORDER: FORENSIC NURSING IN CANADIAN EDS STILL COMING OF AGE Linda McCracken, RN, describes forensic nursing in Canada as still being in its infancy, but there are signs of growth. One issue with which many nurses must contend is working with patients they might not even realize are forensic cases. McCracken says: I think of forensic nursing as something you are doing everyday, but there are some nurses who don’t understand this. I think of it as being in the right place at the right time to be involved in forensic cases, while others may think they are in the wrong place at the wrong time.

55

Working in emergency nursing for so many years, get involved in cases you didn’t even know were forensic . . . until the day you get subpoenaed to go to court. I have gone to court as a factual witness many times. It’s because I usually was the one who took the samples from the doctor when he did the sexual assault exam and handed them to the police officer. Because of this action, I am subpoenaed to go to court to say “Yes, I was working that day,” “Yes, that patient was there,” and “Yes, I took the samples and handed them over to the police.”

McCracken recalls a time when she was involved in the case of a local socialite who was stopped by the police and a scuffle ensued: The police were charging her with assault. She came to the ER with some bruises and small scratches, nothing too significant; however, in my experience, no matter how small the presentation of injury, it is wise to document carefully, because I assume it could go to court. I’m very astute in my documentation, and I try to tell other ER nurses how important that is. Your documentation is your testimony; you may go to court years later and you won’t remember the details of the case, so you’ll be glad you wrote them down. So, in the socialite’s case, I must have had three pages of charting for no real injuries, and sure enough, it was a year later that I was subpoenaed not for the prosecution like we usually are, but for the defense, and there was my chart, laminated as Exhibit A. It included things I had documented, and I thought, “This is something important added on to my role in the ED—being a witness to the evidence.”

McCracken points to a former medical examiner in Calgary, John Butts, MD (who in 1994 had investigated the Swiss Air crash in Nova Scotia), for being one of the earliest proponents of forensic nursing. “He was and continues to be pro-nursing,” she says. “As early as 1976, he recognized that emergency nurses were the ones who had important assessment skills, and began training them to work with forensic cases.” McCracken explains that Butts and forensic nursing pioneer Virginia Lynch were conducting a Canadian-wide lecture tour and speaking about forensic science in the clinical environment. “They hit Calgary in 1994, and myself and a girlfriend who is now the sexual assault coordinator for a hospital here in Calgary, bought into the whole idea of forensic nursing,” McCracken recalls: The person who set it up this lecture tour was a forensic psychiatric nurse at a hospital here who taught forensic nursing as an option in the nursing degree program. I connected with her, and in 1996, when I was president of the Canadian emergency nurses group, we brought Virginia back to Alberta. During a two-day workshop at our group’s annual conference, we got Virginia connected with the people at Mount Royal College, and through

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Forensic Nursing

discussions, they agreed to develop a forensic studies program. And now it’s booming.

McCracken believes this is a step in the right direction, but grouses over the lack of master’s programs in forensic nursing, as well as the lack of nurse representation in forensic services in clinical settings to begin with: There are just a handful of sexual assault nurse examiner programs; they had one in Edmonton and one in Ontario, but that’s still spotty because here in Alberta, our physicians won’t let nurses do these kinds of exams. They believe that we’re not qualified as experts in sexual exams and that too many cases would be lost. Go figure. So, forensic nursing is just getting started in Canada, and we’re way behind the United States, but it’s catching on, though.

McCracken says that in the past, her province has not had as many crimes related to weapons due to a smaller overall ownership of weapons; however, she says she does see a significant amount of interpersonal violence and an increase in violent crime. “I have been in nursing for 31 years, with 26 of those years in emergency nursing in a tertiary trauma center, and the knife-andgun club is thriving. We need forensic nursing in the health care system to make sure health care providers document appropriately so that the victims will get their just rewards in the end. By the time things go to court, if it’s not charted, it never existed.” McCracken says that documentation is challenged by Canada’s privacy act: What we struggle with here is a privacy act that is almost turning hospitals into havens for criminals. There is no federal or provincial law that states if someone comes in as a victim of a gunshot wound, or even if they were the person who did the shooting, that says I have to report it to the authorities. It’s almost like the lawyer–patient confidentiality assurance; in health care they want it to be so people will come to the hospitals for their health’s sake without being afraid that we will report everything to the authorities. If many people with injuries thought we’d report everything, they believe patients would feel that they were in trouble, and would not tell us important things related to their injuries or to their overall health and long-term survival. They want hospitals to be that safe haven where people can freely say what has happened to them. Now certainly we have laws that if someone has TB or some other communicable disease, we must report it, or if you suspect child abuse, you have to report it. Physicians have to report if someone has had a seizure, but otherwise, there is nothing else required.

McCracken adds, “It’s different when there has been a shooting and paramedics are responding to the scene; they have called the police, so they are already involved. It’s the cases that are being tossed at our door or patients

walking in off the street that provide the biggest challenges.” McCracken notes that a draft of a document for the sharing of verbal information between authorities and health care workers is underway: Officers will call and say there was a breaking-and-entering and there’s a lot of blood at the scene; they ask us to alert them if someone shows up with lacerations. I have to say, “Sorry officer, I can’t tell you anything.” Our lawyers tell us that if a patient with those kinds of injuries walks into the hospital, what we can do is phone the police and say, “Why don’t you come over for coffee?” That’s just stupid. They have seen that health care workers are in conflict after all, the nurses are in the trenches, while legal advisors aren’t there after hours for us to talk to. So they have developed a form so that health care workers and the police can share verbal information. The police officer would bring in the form when he is investigating a case; he has to meet certain criteria whereby he has given the nurse enough information so that the nurse can determine if a person is indeed in our department. But it’s all verbal.

McCracken says the present situation is not ideal, but she hopes that future progressive thinking will address the cracks in the system, including how law enforcement interacts with nurses and other health care providers. McCracken says: It shouldn’t be about protecting one’s turf or watching one’s back; I have struggled to convince everybody there must be a multidisciplinary approach. I help officers when they come into the ER; after all, they are out of their turf, and they don’t know what to do. But some nurses and doctors don’t want them in the ER, thinking they have no business there. I did a lecture a few years ago on what forensic nursing is all about in emergency care and told attendees to “Go where there is no path and leave a trail.” My mother had shared that quote with me and I thought how appropriate that was. That’s exactly what forensic nurses are doing. We must be cautious because we are still working for the health care system, and you don’t want to infringe on that, and we’re not working for the police—we are simply trying to link everybody together for the benefit of our patients.

4.3.2 OTHER REALMS

OF

FORENSIC PRACTICE

Although the ER is still a common portal through which forensic patients present, the operating room (OR) is another department in a health care institution in which medical personnel should be familiar with proper protocol—especially when a forensic case might pass through the ER directly to the OR. Evans and Stagner (2003) write, “Whether or not a perioperative nurse has formal training in forensic nursing, he or she must ensure proper collection and disposition of evidence. The perpetrator of a crime should not go free

Forensic Issues in the Clinical Setting

because forensic evidence was mishandled; however, protocols for collecting evidence and maintaining the chain of custody often are not clearly established.” For example, they ask, what happens to a bullet once it is turned over to the pathology department? Is it guarded continuously or locked in a controlled area? Can a nurse confidently state that the chain of custody remained unbroken and evidence has not been tampered with if called on to testify in a court of law? Evans and Stagner explain, “Commonly, forensic evidence collected surgically is sent to the pathology department as a biological specimen. Bullets, in particular, are pieces of evidence that can be altered by pathology procedures, and many times, the proper chain of custody is not maintained during the process. These forensic specimens should be collected as such initially and transferred to the appropriate authority as soon as possible.” According to Evans and Stagner, perioperative nurses are responsible for identifying, collecting, and preserving evidence and for securing evidence in a designated area of the OR to establish and maintain the chain of custody. Evidence collection in the OR follows similar steps of evidence collection to those elsewhere in the hospital. The first step is to identify potential forensic evidence, including clothing, and debris caught in the patient’s hair or lodged in the skin. According to Evans and Stagner,: The most common types of physical evidence identified in the OR are bullets; pieces of glass, wood, or paint; and bloodstained clothing. A forensic nurse examiner may be required to collect additional evidence, by hair combing, swabbing, and fingernail scraping or by performing an examination for sexual assault. If a physician requests a comprehensive medical forensic examination, the forensic nurse examiner on call should be notified to conduct the examination. A full medical forensic examination includes taking a patient history and conducting a headto-toe assessment for trauma, including a detailed genital examination, to evaluate forensic evidence.

In the OR, evidence should be handled with equal care, with perioperative nurses wearing gloves at all times. Evidence must be collected in a manner that does not contaminate the specimens so that a medico-legal investigation of suspicious injury or death is not compromised. Clothing should be removed from the patient without cutting through tears or holes that contain important trace evidence, and because articles of clothing could contain forensic evidence such as hairs, fibers, or the assailant’s blood, they should not be shaken. When removed from the patient in the OR, clothing should be placed on a clean white sheet on the floor in a corner until time permits for proper packaging. Evans and Stagner say each piece of clothing should be placed in a separate paper bag with a clean white sheet of paper placed over stains to avoid cross-contamination.

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To maintain the chain of custody, Evans and Stagner say the bags should be sealed with evidence tape and labeled with the patient’s name, the date, the time, and the signature of the person responsible for collecting and securing the evidence. These bags should be placed in a secured area of the OR where there is no chance of contamination by fluids. Best practice includes placing the evidence and appropriate chain of custody forms in a locked drop box that contains a refrigerator and is located in an area that has limited public access and key access for designated personnel only. Evidence must be kept in the drop box until the forensic nurse examiner or law enforcement officer takes the evidence into his or her possession. Clothing never should be placed in plastic bags because this can result in cross-contamination and degradation of the evidence. If clothes are wet or damp, they should be allowed to air dry. If moisture still is present and there is a chance of leakage, the sealed clothing bags should be placed inside a larger paper bag with the top of the second bag left open. A label should be attached to the outside of the bag to alert crime laboratory personnel that wet evidence is present. Law enforcement officers should be notified immediately to pick up wet evidence. Wet evidence never should be stored in the drop box. Dry clothing can be stored in the drop box until it is turned over to law enforcement officers or a forensic nurse examiner. This is important to ensure the chain of custody is maintained. Perhaps one of the most important pieces of forensic evidence might still be lodged in the patient’s body. Evans and Stagner write: Projectiles or penetrating devices should be safeguarded against mutilation or damage. Bullets should be removed with rubber-shod forceps to avoid causing artifact to the bullet, wrapped in cotton, and placed in a peel pack. Bullets should be handled as little as possible and never should come into contact with a metal surface. The peel pack should be sealed with evidence tape, labeled, and placed in the drop box or given to the forensic nurse examiner or law enforcement officer, if one is available. Large penetrating devices, such as knives, should be placed in a double peel pack with the outside pack left open and then placed in an open paper bag with appropriate labeling. The evidence then is secured in the locked drop box.

Perioperative nurses might encounter patients coming into the OR with bagged hands to protect trace evidence or gunpowder residue. Evans and Stagner advise, “Should it become necessary to remove the bags, the gunpowder residue must be collected. Prefabricated kits are available to assist in the collection of residues from shooting suspects or victims. Either cotton swabs or adhesive applicators are used to recover gunpowder particles that later can

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Forensic Nursing

be analyzed to determine the type of ammunition from which the gunpowder came.” Evans and Stagner emphasize: Perioperative nurses have a professional responsibility to ensure that their educational needs regarding evidence collection and preservation are met, whether through formal education in forensic nursing programs or reviewing the policies and procedures at their facilities. If necessary, they should seek information to help establish protocols for collecting and handling evidence and maintaining the chain of custody at their facilities. Competent handling of forensic evidence may be the deciding factor in whether a violent offender is found guilty or not guilty. It is a nurse’s responsibility . . . to ensure that patients’ rights are upheld.

4.4 SUDDEN, SUSPICIOUS, OR UNEXPECTED DEATH IN THE HEALTH CARE ENVIRONMENT The presence of severe illness and death in the health care environment is a given; however, it is precisely this setting that invites suspicious activity of perpetrators intent on causing harm to the vulnerable patient populations who entrust their very health and welfare to hospitals who are treating them. Health care professionals must be aware of the various opportunities for assaults, injuries, and deaths triggered by outside agents and assailants, as well as their clinical colleagues. Forensic nurses are well appointed and positioned to recognize and respond to sudden, suspicious, or unexpected death in the clinical setting. Lynch (1997) writes, “Life-saving priority is obvious to nurses in catastrophic, near-death treatment. Yet the importance of properly identifying, securing, and preserving items that can later be considered as evidence may be forgotten when the patient dies.” The hospital environment can very quickly become the scene of a crime, and forensic nurses must know how to operate within these parameters. Lynch adds, “If death occurs in the trauma room, for example, the trauma room suddenly becomes a scene of legal inquiry and is listed as the place of death on the death certificate regardless of where the initial incident occurred. The death scene must be protected until the body and the evidence have been removed at the completion of the medico-legal investigation.” It is then incumbent on the forensic nurse to provide accurate documentation, detailed description of wounds, collection and preservation of physical evidence, and the gathering of medical records and reports. Georgia Pasqualone explains that forensic principles remain the same, regardless of the setting in which the death occurs: The principles of forensic science are the same, and the principles of the nursing process are the same, no matter

the environment. Today, nursing is not bound by the four walls of the hospital; nurses are out at crime scenes in the community, too. Death is usually associated with events outside of a hospital, but no matter where a crime scene occurs, the nursing process is the same. Nurses are still in charge of essential components such as assessment, diagnosis, intervention, evaluation . . . the way a nurse thinks, the way a nurse puts it all together, it’s the same no matter what the environment of the situation is. Nurses must recognize evidence for what it is, they must collect it, preserve it, document it, photo-document it—nurses must be especially careful to adhere to forensic science and medico-legal principles or a case is going to fall apart.

Lynch (1995) states, “Sudden and violent deaths most frequently represent the initial interface between the hospital staff and police in the emergency department. Considering the number of sudden and unexpected deaths that occur in the clinical setting, nurses have a critical role to play in providing answers in questionable death situations.” She explains that deaths occur frequently in the hospital environment, and might include patients who are dead on arrival, those who die during trauma treatment, patients who die on the operating table or in the delivery room, and patients who die in the ICU. “Deaths which occur as a result of trauma or unknown causes require investigation,” Lynch writes. “Generally, any death that occurs during the first 24 hours after admission is reportable to the medical examiner/coroner system regardless of the history.” Lynch (1997) explains that if a patient death occurs in the trauma room, that room instantly becomes “a scene of legal inquiry and is listed as the place of death on the death certificate regardless of where the initial incident occurred.” It is essential that health care personnel protect this death scene until the body and the physical and trace evidence have been removed at the completion of the medico-legal investigation. Lynch adds, “Patients who die as a result of abuse or an accident must be reported; there must be investigation; and evidence must be retained.” She emphasizes the role of the forensic nurse in these situations: “Who is responsible for preserving the scene, interviewing the witnesses, collecting evidence, and managing forensic issues until the investigation is turned over to the proper authority? The presence of a nurse skilled in forensic technique and appropriate medico-legal procedures may be essential in each of these situations.” In Chapter 1, the nurse’s index of suspicion is addressed. Lynch states that “maintaining an index of suspicion is essential when considering criminal activity as a cause of sudden and unexpected death.” She adds that “preservation of evidence, careful documentation of the circumstances surrounding the death, and the decedent’s social and medical history may form the basis for deducing the cause of death when it is not obvious.” A forensic nurse plays a pivotal role in identifying pieces of evidence that

Forensic Issues in the Clinical Setting

can speak volumes about the details of the case and the specific events leading up to the suspicious or suddendeath event. Lynch explains: Often overlooked is the proper handling of items that might subsequently be considered evidence. Full documentation of the appearance of the victim on arrival at the hospital is also often neglected. Nurses are among the first to come in contact with the patient, interview family members, and handle the patient’s property and laboratory specimens. They serve as a vital link between the victim, police, and medical examiner or coroner. Generally, the nurse elicits information that may clarify important points related to the cause or manner of death, and the nurse is often the first person to have access to evidence of a criminal nature in the medico-legal sense.

The first step in any sudden, suspicious, or unexpected death is to determine “whether the initiating cause is natural or unnatural,” Sullivan (in press) writes: It is not uncommon for physicians to incorrectly identify the cause of death because of failure to differentiate between cause, manner, and mechanism of death. Increasingly, states are passing nurse pronouncement laws, and nurses are pronouncing death. With the extent of greater involvement in death pronouncement, a clear understanding of these terms must become an essential component of nursing education. Although the nurse may not be filling out the death certificate, the data recorded in the chart is often copied by less knowledgeable people; therefore, it is vital that the entry be appropriate.

In Chapter 6, the cause, manner, and mechanism of death are explored in greater detail. In the clinical setting, nurses must remember that the cause of death is the injury or disease (or combination of the two) that is “responsible for initiating the sequence of disturbances that produce the fatal termination,” according to Sullivan. Manner of death is the circumstance in which the cause of death arose, and is categorized as natural, accident, homicide, suicide, or undetermined. According to Sullivan, mechanism of death is the “physiologic derangement or biochemical disturbance incompatible with life initiated by the cause of death.” Many deaths are anticipated or can be explained by age or disease processes, and these are traditionally considered to be natural deaths. They are not subjected to investigation and are normally handled by the attending physician, who will attest to the death due to natural causes. Conversely, sudden death is any death that was not expected, and might involve the patient’s respiratory system, cardiovascular system, or central nervous system. According to Sullivan, the term sudden death usually is attributed to deaths “occurring in less than five minutes, frequently with instantaneous immobility.” She explains, “In the absence of suspicion, unexpected deaths should

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fall within the jurisdiction of the medical examiner/coroner if no recent medical attention for a natural disease is documented. In contrast, unexpected deaths that are unnatural may include trauma, either intentional or unintentional; suicide, self-inflicted injury with the intention of taking one’s own life; and homicide (injury inflicted by another with intention to kill); these require reporting to a legal agency.”

4.5 HEALTH CARE SERIAL KILLERS Nurses serving in a forensic capacity often are the first responders to victims sustaining suspicious injuries; however, what if the nurse is the perpetrator of these injuries or even death? Health care providers who kill their patients tread on and exploit the inherent trust built into the health care profession; what better place to experiment with murder than among the ill, the injured, and the dying in a hospital environment? Interventions designed to kill can be more easily camouflaged by the interventions intended to heal; it is the subtleties that can reveal the health care professional’s intentions, and no one is better trained than the forensic nurse to note these minute details and collect evidence that documents them. Health care serial killers are nothing new, but lately they have been making headlines far more frequently. The Philadelphia Inquirer reports that in the last three decades, there have been at least three dozen such cases in civilized societies, with many more suspected but as yet unproved cases. “This is a more common problem than is known, and it’s getting worse as the population ages,” observes forensic pathologist Michael Baden, MD, chief medical examiner for the New York State Police. According to Court TV’s Crime Library, “Some enter the profession as ‘angels of death,’ while others transform into killers on the job.” Since the mid-1970s, there have been 36 cases of serial murder among nurses and other health care workers in the United States. A survey shows that the incidences appear to be increasing, with 14 during the 1990s and already six since 2000. Many experts speculate that health care has contributed more serial killers than all other professions combined and that the field attracts a disproportionately high number of people with a pathological interest in life and death. They prey on vulnerable populations such as the very young, the very old, the disabled, the very ill, and anyone else who might not be able to fight back and report suspicious activity on the part of a health care provider. Former New Jersey nurse Charles Cullen, who said he killed as many as 40 of his patients, was convicted of 16 murders; he pleaded guilty on May 19, 2004 to three counts of first-degree murder, according to Warren County Prosecutor Thomas Ferguson. The charges involved the 1983 deaths of Helen Dean, 91; Lucy Mugavero, 90; and Mary Natoli, 85. All three were patients at Warren Hospital

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in Phillipsburg, New Jersey, where Cullen worked. Cullen had worked as a nurse for almost 20 years at hospitals in Pennsylvania and New Jersey. He faces several consecutive life terms in prison. Cullen, who earned his RN degree in 1987, was initially charged with murder in the death of a patient at Somerset Medical Center in New Jersey who was found to have lethal levels of the drug digoxin in his system. An original attempted-murder charge stemmed from a female patient who recovered from an overdose of the same drug. According to investigators and media reports, Cullen was fired after an investigation of six patients with abnormal lab results showed him as the only common denominator. According to Court TV’s Crime Library, a toxicologist at the New Jersey Poison Information and Education System had informed the medical center in July 2003 that he had identified a cluster of at least four poisoning cases. The facility’s administrators ignored the warning, according to reports in the Newark Star Ledger. Just one year earlier, nurses at St. Luke’s Hospital in Bethlehem, Pennsylvania, had cautioned the state nursing board, law enforcement officials, and the county coroner that Cullen could be a murderer, after identifying a noticeable increase in the number of code blue incidents, according to reports in the The Morning Call. Additionally, nurses at two other facilities demanded that Cullen be dismissed and investigated, but administrators declined. Even with outright warnings of potentially criminal behavior on his part, Cullen’s employers continued to hire and retain him; many point to the severe nursing shortage as sufficient reason to hire a nurse—any nurse—on the spot. According to USA Today, Somerset Medical Center representatives stated they did not know that Cullen was under investigation elsewhere, and that when his credentials were checked, there was no reason not to hire him. However, there are reports that dates of employment were the only pieces of information that were verified. Observers might be astounded by the fact that health care serial killers go years without being detected, or when they are, can continue to work in the health care system without their criminal behavior being recognized and stopped, and eventually investigated and prosecuted. Court TV’s Crime Library states, “While arguments have flown back and forth over the Cullen case in terms of ultimate responsibility, it’s clear that patients must depend on hospitals and clinics to spot the red flags and do something about them. Too often, these killers have been allowed to drift from one hospital to another, fired under a cloud of suspicion but rarely brought to justice until after incriminating evidence has reached shocking levels.” Health care institutions state that they could be sued if they act on their suspicions in a way that prevents an individual from being hired. According to reports by The Morning Call, hospitals can also be sued for not doing so, and their insurance carriers will not cover them. Inten-

Forensic Nursing

tional acts of murder are not considered part of professional practice, insurers claim. Court TV states, “If families move ahead on their threats to sue those facilities that did not voice suspicions when asked or did not warn other potential employers of Cullen, this case might become a real wake-up call.” One of the more chilling cases was that of Kristen Gilbert, a 30-year-old nurse indicted in 1998 for murdering four of her patients and attempting to kill three others by injecting them with epinephrine. Gilbert worked at a Veterans Administration (VA) medical center in Northampton, Massachusetts, and although her patients often were elderly, the majority was not in acute distress or immediate danger of death, and investigators maintained they were not mercy killings. Prosecutors charged that Gilbert enjoyed injecting epinephrine into her patients and then calling codes so she could meet up with a security guard with whom she was having an affair. Defense attorneys argued that the government could not prove foul play; considerable amounts of circumstantial evidence as well as Gilbert’s inculpatory statements were met with a lack of eyewitness testimony. Judge Michael Ponsor said, “The trial presented . . . a classic battle of experts” in a Boston Globe article, adding that the extensive prosecution and defense teams of experts cost more than $1.6 million of taxpayers’ money. More than 250 motions and hundreds of hours of hearings later, the jury began its deliberations. On March 14, 2001, after 12 days of deliberation, the jury delivered its verdict of guilty on three counts of first-degree murder as well as several lesser charges. The complexity of the Gilbert case might explain why the jury, in the penalty phase of this capital case, pronounced themselves deadlocked, and imposed the default sentence of mandatory life imprisonment without possibility of release. Three jurors said that although the evidence was strong enough to prove guilt beyond a reasonable doubt, it was too weak to justify the death penalty. There is no state death penalty in Massachusetts, but Gilbert was eligible for it under federal law because her crimes took place on federal property at the VA hospital. On March 27, 2001, Ponsor sentenced Gilbert to four consecutive life terms without the possibility of parole for killing four patients, and also sentenced her to two 20year terms for trying to kill two other patients. Assistant U.S. Attorney William Welch had called Gilbert “a shell of a human being” who deserved to die for the calculating way she murdered her victims. On July 25, 2003, Gilbert dropped her federal appeal. If she had won a new trial on appeal, a recent U.S. Supreme Court ruling would have allowed prosecutors to seek the death penalty. The Gilbert killings are some of at least 35 other serial murders committed by health care personnel (mainly nurses, but also including a respiratory therapist and several physicians) since the mid-1970s, says Beatrice Crofts

Forensic Issues in the Clinical Setting

Yorker, RD, JD, FAAN, an expert in psychiatric mental health nursing and nursing jurisprudence. Four occurred in the 1970s, 12 in the 1980s, 14 in the 1990s, and at least five in the 2000s, including the more recent cases of Richard Williams in Missouri in 1992, Orville Lynn Majors in Indiana in 1995, and Vicki Dawn Jackson in Texas in 2000. According to Yorker’s analysis, at least 26 murders occurred in hospitals, nine of which took place in the ICU. The nurses used injection of noncontrolled medication such as insulin, digoxin, lidocaine, epinephrine, and other respiratory paralysis agents. Males are disproportionately represented, Yorker says, accounting for 38 percent of the perpetrators. “Serial killers in health care appear to come in basically one of five guises: those who kill out of mercy, those who want to feel like God, those who kill for an erotic thrill, those who are mentally ill, and those who just feel overburdened,” says Katherine Ramsland, PhD, who teaches forensic psychology at DeSales University in Pennsylvania. “All of these types have been around because all of these motives arise out of human nature.” Netherlands researcher Paula Lampe reports that since 1970 in her country, there have been four male and five female health care killers who are nurses, whereas globally, that number amounts to 81 cases. She says of these, 31 are male. Male nurses are disproportionately represented among caretakers who harm patients. Although there are many more cases, quantitatively, of women who indulge in this behavior, Yorker, director of the School of Nursing at San Francisco State University, reports that the approximately 146,000 male RNs represent 5 percent to 7 percent of all nurses, yet are responsible for more than one third of individuals who have killed patients in the United States since 1975. When Donald Harvey worked at Marymount Hospital in London, Kentucky, in 1970, he would smother his patients with a pillow to ease them out of their suffering. Following an arrest for burglary, a stint in the Air Force, and a commitment to a mental health facility, Harvey got work as a nursing assistant at several health care facilities in the Lexington, Kentucky area, moving on to the Cincinnati VA Medical center in Ohio, where for nearly a decade he worked in various capacities as a nursing assistant, housekeeper, and autopsy assistant. In 1985 he was forced to resign on the basis of possession of a firearm at the facility. He immediately began working as a nursing assistant at Drake Memorial Hospital, where it was reported he killed more than 20 patients by injecting them with lethal substances such as arsenic, cyanide, and petroleum-based cleansers before his arrest in April 1987. According to the Court TV Crime Library, the death of patient John Powell “finally brought Harvey down.” During Powell’s autopsy, the forensic pathologist detected significantly elevated levels of cyanide, and the death was ruled a homicide. Harvey was arrested, but he pleaded not

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guilty by reason of insanity; it was then that he confessed to killing 33 people, then 52, then more than 80. He said that most of the murders were mercy killings. He was declared sane and competent for trial by a psychiatrist who examined him. In a Cincinnati courtroom on August 18, 1987, Harvey pled guilty to 24 counts of murder and four counts of attempted murder. Then he added another murder plea, which earned him four consecutive life sentences. In Kentucky, Harvey admitted to 12 more murders but entered a guilty plea on only nine of them; in that state, he received eight life terms, plus 20 years. In Cincinnati again, he confessed to three more killings and three more attempts at murder, amounting to a total of 37 official murder victims. Harvey is said to hold the U.S. record for the most confirmed number of victims of any health care serial killer. “Since 1974, at least 12 nurses have been charged with murder following mysterious epidemics of adverse patient incidents,” Yorker (1994) wrote in the Journal of Nursing Law. “In some cases, the CDC confirmed an epidemic of cardiopulmonary arrests and attributed them to the presence of a particular nurse ... Until recently, social scientists dismissed the idea that female serial killers existed. Since the 1970s, however, research shows that female serial killers do exist and are convicted.” She points to research by Holmes, who discusses five types of female serial killers: women who kill in response to voices or visions, women who kill for money, hedonistic killers who obtain pleasure from killing, disciples who kill under the influence of charismatic leaders, and power seekers who deliberately put their patients at risk so they can rush in and save them to appear heroic. Ramsland says that even though they are easier to spot these days, they are driven by centuries-old motivations. “They have had access to poisons since the earliest of times. It’s more difficult for them now, because victim counts stand out, professionals are more alert to killers among them, there are better surveillance methods, and we have methods of accountability that did not exist decades ago. We know more about them now because we have better documentation, but they have been around for centuries.” “Males tend to be more involved in playing God, feeling power over human life, and finding an erotic thrill in that, although we’ve certainly had cases of nurses who found killing so exciting that they immediately had to have sex,” Ramsland explains. “More health care workers claim they killed patients out of a sense of mercy, yet further analysis tends to dispel this motivation. Often they’re seeking attention, they’re acting from some delusion, or they’re trying to prove something. I think it’s a myth that most health care workers who kill do so because they want to do a kindness.” Richard Angelo claimed that he was motivated to save people rather than kill them, and experts believed that as

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a charge nurse at Good Samaritan Hospital on Long Island in New York, Angelo could capitalize on situations that made him look like a hero—similar to the Gilbert case. Injecting a foreign substance into the IV tube of a patient, John Fisher, Angelo triggered an adverse reaction in the patient, who died before Angelo could save him. This failure to rescue did not deter Angelo, however. According to Court TV, in a taped confession Angelo commented, “I wanted to create a situation where I would cause the patient to have some respiratory distress or some problem, and through my intervention or suggested intervention or whatever, come out looking like I knew what I was doing. I had no confidence in myself. I felt very inadequate.” A patient named Gerolamo Kucich was Angelo’s downfall. Kucich saw a bearded man inject something into his IV, and was able to press his call button; the patient survived, and described the perpetrator to nurses who made the connection to Angelo. Kucich’s urine test was positive for Pavulon and Anectine, paralysis-inducing drugs that had not been prescribed for him. When Angelo’s apartment was searched, investigators located and seized vials of the drugs, and arrested Angelo. Following a confession of killing at least 10 patients, the bodies were exhumed; tests revealed traces of the drugs in those patients’ systems as well. Charged with multiple counts of second-degree murder, at his 1989 trial Angelo pleaded to temporary insanity at the time of each killing. Despite being diagnosed by psychologists as having dissociative identity disorder, Angelo was convicted of two counts of second-degree murder, one count of second-degree manslaughter, one count of criminally negligent homicide, and six counts of assault; he was sentenced to 61 years to life. Another high-profile case was that of licensed practical nurse Orville Lynn Majors. Shortly after he came to work at the 56-bed Vermillion County Hospital in Clinton, Indiana, in 1993, there was an increase in number of deaths occurring in the ICU. That year, there were 26 deaths in the ICU; in 1994, there were 101 deaths, with 67 of them occurring in the last half of the year and 63 of them during Majors’s work shifts. In Majors’s 22 months of employment, 147 patients died, and most of them were under Majors’s care at the time. A perceptive nursing supervisor became suspicious, and when Majors’s license was suspended in 1995, the hospital’s death rate returned to its normal baseline. It was later determined by an independent statistical report on all of the deaths that patients were 43 percent more likely to die at the hospital if Majors was working a shift. According to Court TV, an investigation of 160 deaths between May 1993 and February 1995 revealed that Majors sometimes provided unauthorized “treatment” to his patients. Fifteen bodies were exhumed to test the patients’ tissue, and investigators found that at least six deaths were consistent with the administration of epinephrine and potassium chloride. A search of Majors’s house

Forensic Nursing

revealed syringes, needles, and vials of the two drugs, as well as vials of potassium chloride in Majors’s vehicle. Majors was suspected of having caused as many as 130 deaths, and in December 1997, he was arrested and charged with six counts of murder. On October 17, 1999, Majors was convicted of six counts of murder, for which he received a sentence of life in prison. There are several other notable cases of health care serial killers in the vaults of Court TV’s Crime Library. In the United Kingdom, nurse Kevin Cobb was convicted in May 2000 of one count of manslaughter, two counts of rape, and four counts of drugging women with intent to rape. He received seven life sentences. Atlanta nurse Joseph Dewy Akin was suspected of being responsible for more than 100 deaths in a span of 10 years when working for more than 20 health care institutions; he was sentenced to 15 years in prison after pleading guilty to manslaughter. Swiss health care provider Roger Andermatt was arrested for the murder of 24 patients, and also charged with the attempted murder of three patients. Another three deaths were classified as assisted suicide. He confessed to all of the murders, which occurred between September 1995 and June 2001 in nursing homes in and around Lucerne, Switzerland. The victims, some as young as 66 and others as old as 95, either had Alzheimer’s disease or were in need of high levels of care. Nine patients were killed with lethal doses of medication, eight patients were smothered with a plastic bag or a cloth, and 10 patients were killed using a combination of drugs and smothering. Trial was pending at the time of writing. In 2001, Japanese nurse Daisuke Mori was arrested and charged with the murder of an 89year-old patient. Mori was also charged with four counts of attempted murder of a 1-year-old girl, an 11-year-old girl, a 4-year-old boy, and a 45-year-old man, also patients at the Hokuryo Clinic in Izumi Ward, Sendai. Prosecutors claimed that Mori administered a muscle relaxant to his victims through an intravenous drip, implying that he replaced a bag that was prepared by other nurses with one that contained the lethal doses. The alleged attacks occurred between February and November 2000, but there were no witnesses to the alleged acts. Mori originally confessed to the crimes, but then recanted and pleaded not guilty to the charges. At the time of writing, the case was pending. In the Los Angeles County suburb of Glendale, California, hospital therapist Efren Saldivar was implicated in the 1996 respiratory failure of a 75-year-old woman who was found dead in her bed, even as she had been expected to recover and return to her home. In March 1998, Salvidar confessed to murdering 50 patients for ”humanitarian reasons.” Investigators exhumed 20 bodies and tissue samples were tested for the presence of Pavulon. Of six patients exhumed, five had not received Pavulon as part of their legitimate medical treatment prior to their deaths. Salvidar was arrested in 2001, and admitted to killing at least 60

Forensic Issues in the Clinical Setting

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patients; he pleaded guilty to six murders and is serving a life sentence in prison. According to various reports by the Associated Press, Columbia, Missouri nurse Richard Williams was indicted in 2002 for killing 10 patients a decade earlier. A former VA hospital employee, Williams was charged with administering succinlycholine, a derivative of curare, to nine men and one woman in his care. Their ages ranged from 58 to 85. Helping to secure these charges was new technology able to detect this pharmaceutical in human tissue in a way that was previously impossible, as well as the statements of more than 100 witnesses. The charges were later dismissed when issues with the test developed, and Williams maintained his innocence throughout, despite being accused of as many as 24 deaths. Although profiling has played a significant role in catching killers, Ramsland says:

It is common that people get away with murder in a hospital or community health setting for quite a while, partly because of denial. Many people cannot believe that someone in a helping profession would actually kill his or her patients. Many people also cannot believe that women would commit serial murder (though we have many, many cases). Sometimes people are protected by a hospital trying to avoid bad publicity, so they’re sent away but not stopped, as in the case of Dr. Michael Swango. I believe that Dr. Harold Shipman, who may be the worst serial killer among them with a victim count over 200, often made house calls and had such a kindly air that no one suspected. For the most part, it does seem that the medical community has a code of protection and people are loathe to turn someone in, especially if circumstances are ambiguous. We’ve seen cases where whistleblowers get fired or bullied, while the killer continues to work. It’s often a delicate situation, and good psychopaths know how to manipulate it to their advantage.

There’s no way to provide a general psychological type, because each killer that I’ve studied is quite unique in his or her own framework. One man killed to ease his workload, another to experiment. Two women killed to prove their love to each other. Another liked watching her boyfriend come running in an emergency. A male nurse talked about supernatural issues. Another was suffering from Munchausen by Proxy Syndrome. As with most other types of crime, each case is unique to the person.

Investigators have pinpointed the red flags that signal suspicious activity. Bruce Sackman, special agent in charge of the Northeast field office for the Office of the Inspector General, was one of the investigators on the team that played a key role in bringing Gilbert to justice. He offers the following list:

Ramsland says the most susceptible patients are children, especially babies, and the elderly, because their deaths can be easily explained by natural causes. Even using epidemiological data to connect an unusually high number of these deaths from seemingly “natural causes” has not been foolproof in building and trying a case. In one case in Maryland where an epidemiologist testified that patients of a particular nurse were 47.5 times more likely to have a cardiac arrest (100 times more likely on the night shift), the judge ruled the evidence in the case was only circumstantial and could not be used as evidence of intentional acts, Yorker says, because the state-of-mind element of proof was missing. Although not effective in a criminal case, this kind of statistical evidence can be very persuasive evidence in a wrongful death lawsuit, Yorker says, due to differences in burden of proof between criminal and civil suits. In the Maryland case, although the nurse was acquitted of murder, she faced eight civil suits that settled for $8.5 million. Regardless of the outcome, the real challenge might be in warranting the arrest and bringing the case to trial in the first place. For six months, Gilbert went on a killing spree before several of her nursing colleagues could no longer ignore the number of sudden deaths occurring on her watch. Says Ramsland:

• • •

•

•

•

• • • •

• •

Statistically, a patient’s risk of harm is significantly greater when treated by the subject. The subject is uncommonly accurate in predicting patients’ demise. Patient deaths were unexpected by staff or family, and the family was not at the patient’s bedside. Death certificate cites the patient’s last illness as the cause of death, or a catch-all is noted, such as cardiac arrest. Initial review usually finds insufficient evidence to pursue the case, with buy-in from management. The subject often continues patient care during investigation, and is removed only after allegations become public knowledge. Fellow employees often report allegations to investigators, not management. There are no eyewitnesses to the crime. Witnesses say they saw the subject with the patient shortly before the patient died. The weapon of choice is usually a sudden death chemical readily available on the ward and often considered nondetectable or not checked at autopsy. Syringes, IV lines, and feeding tubes are the most likely portals of entry if poison is used. If a code is called, EKG strips should be in the chart; their absence should raise suspicions.

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Forensic Nursing

• •

• • • • • • • • • •

•

•

•

Subjects are often charming and friendly, yet have difficulty with personal relationships. The subject receives good written reviews from supervisors, although prior employment records show questionable incidents. The subject is given nicknames by the staff while still employed. Drugs, poisons, and related books are found in the subject’s home. Killing is nonconfrontational. The subject insists patients died of natural causes. The subject never shows remorse for his or her victims. Other patients complain about the subject but their comments often are ignored. The subject craves notoriety. Evidence exists that the subject killed or attempted to kill off duty as well as on duty. A subject likes to arrive early or stay late on a shift. An individual enjoys talking about death with colleagues or shows odd behaviors related to the death, such as excitement, ownership, or undue curiosity. An individual keeps to himself or herself, preferring shifts where fewer colleagues are present. The subject makes colleagues anxious or suspicious, or attempts to prevent others from checking on patients. The subject lingers during the immediate death investigation.

Experts emphasize that no one specific red flag is sufficient to point to a potential health care killer, but a cluster of them occurring together should be taken seriously by health care providers and hospital administrators. Experts like Sackman and Ramsland agree that forensic nurses are in an excellent position to detect suspicious activity in their health care facilities. “If they get trained in criminal behavior, forensic nurses would have a better eye for this behavior, but not all programs offer that,” Ramsland says: A high victim count on someone’s shift is generally the first red flag. A regular incidence of patients going downhill after a particular doctor or nurse has been in their room. A health care worker who appears to have antisocial tendencies, who likes to talk about violence, who shows a high degree of excitement in emergencies, who is secretive, and whose emotional response to incidents seems shallow or superficial is someone to watch. If medicines that may cause coma or death are missing, that’s a red flag. A person who pays a lot of attention to the fatalities for entertainment value rather than to learn could be show-

ing signs of a problem. But again, there’s no general psychological type. No matter what might be offered in terms of a set of red flags, psychology is a field full of novelties. There’s no way to predict what new behavior might arise that we haven’t seen before. But we can study the details of past cases and learn from them in order to see potential red flags sooner.

Evidence goes to the heart of any criminal investigation, and Ramsland says forensic nurses should do everything they can to identify, collect, and preserve it. “Everything is potential evidence,” Ramsland emphasizes: One never knows what small item will make all the difference in a guilty or not guilty verdict. Even nonphysical items, such as a man discussing his fantasy of seeing children die, can have evidentiary value (and has). Forensic nurses are trained to understand the importance of handling evidence, chain of custody, ensuring that specimens are protected from degrading, etcetera. They may be trained in character disorders common to criminal behavior in ways that other nurses are not, and they can spot some of the signals more quickly. They can also use their education in criminality to put pressure on medical boards and administrators to be alert to the cases. Above all, they can keep educating themselves in these cases, because the more one knows about what has happened in the past, the more one is able to recognize an ongoing linked series of incidents and to believe that a serial killer might indeed be in their midst. Education is the best way to erode denial and naivete, perhaps the serial killer’s most lethal allies in the medical system.

With several cases pending and the news of serial killers in the newspapers, one would think the medical boards and institutions are responding to this seeming epidemic of health care serial killers, but Ramsland says health care is guarded about the situation: My impression is that the medical community in general views serial killing as an anomaly and deals with each case after the fact. I think there’s a general atmosphere of institutional self-protection and no one wants to have to make specific policies, other than to ensure better supervision. To do so would be to publicly admit that medical facilities are vulnerable to delusional workers or serial killers. That’s not good for business.

M. William Phelps, author of the book Perfect Poison, which documents the Kristen Gilbert case, says: Forensics is a tool to uncover what has happened—or at least a good perception of the truth as it pertains to science. [Forensic nurses] understand that it is nothing like the TV show CSI. It is more meticulous, more researchoriented, and certainly more time-consuming and unromantic than the show would suggest. For example, if, after a code, you have three spent ampoules of 1:1000 strength

Forensic Issues in the Clinical Setting

epinephrine in a waste basket, another used 1:10,000 bristo-jet package of epinephrine sitting empty on a crash cart, along with EKG readings with spikes that look like a silhouette of the Rocky Mountains, a forensic nurse might be able to put it all together in real time and, at the least, say, “Wait a minute, something seems suspicious here.” And, perhaps the most important observation: “Let’s look into it further.” Granted, forensic nurses generally deal in sexual assault cases. Yet any type of nurse in any health care situation who is observing patient care by other nurses has an obligation to report suspicious activity of any kind, regardless of what it looks like, their personal feelings, or the thought that it might be “nothing.” If there is any question or any doubt, it must be looked into further. I’m tired of that age-old mentality of one professional turning a blind eye to the other simply because they are colleagues. Health care professionals are in the business of saving lives, not making friends and scoring social points.

Chicago forensic nurse Catherine A. O’Brien, RN, MS, CNA, CLNC, D-ABMDI, a registered medico-legal death investigator, says that “several unconventional encounters with death” in her early years as a staff nurse in the hospital setting might have influenced her career choice. She says that she was not in the forensic mindset at the time of these medico-legal moments, but they got her thinking about sudden, unexpected death in the health care environment and how better to respond to the next unanticipated event. She recalls the attempted murder of a known gangster under her care by someone dressed like a respiratory therapist: As I turned the corner and approached the room with the sounding call light, I observed a male figure, dressed in white pants and lab coat, come out of the room and walk down the hall in the opposite direction. Although one of my patients in that room was on oxygen therapy, I recall thinking it odd and too early in the night for respiratory therapy to be making routine rounds. My patient told me he heard muffled, moaning sounds that awoke him. Simultaneously, coughing sounds could be heard from the other side of the curtain. When able to speak, the roommate told me of a suffocation attempt on his life that was interrupted by the ringing call light.

O’Brien says she was devastated at the thought that any patient under her care was victimized: I regretted not having had the foresight to anticipate this possibility due to the patient’s personal history, but after all, hospitals were supposed to be safe environments. I regretted not following my gut instinct about the untimely presence of someone unfamiliar in the environment. Had I been more observant of this male figure, I might have been able to provide law enforcement a more detailed physical description. Perhaps had I verbalized an inquis-

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itive remark to this individual, it may have provided an opportunity to get a glimpse of his face, hear a verbal response, or generate a reaction to share with the police in order to make a valuable contribution to the subsequent investigation.

O’Brien characterizes her experiences as a pediatric intensive care nurse as “tragic.” She reflects: Traumatic deaths due to gunshot injuries, blunt-trauma injuries, patterned injuries, burns, neglect and battering, accidents were common denominators in the demise of many of my vulnerable patients. It was during this decade of my career that collaboration on numerous cases with law enforcement, child protective services, organ procurement teams, hospital general counsel, and the legal process came to the forefront. The intersection between medicine and law in each instance broadened my perspectives, taught numerous lessons, and strengthened my advocacy for victim’s legal, civil, and human rights. The value of meticulous initial and ongoing assessments, detailed and factual documentation as well as testimony presentation cannot be understated. This was particularly evident in one case that involved a toddler in isolation who was under the care of a registered nurse each shift. Periodically, there was a need to leave the room to obtain refrigerated medications, which sometime occurred while the parents were present. On several occasions, my colleagues and I observed that after the parents’ departure, the child’s behavior often would become agitated with increased vital signs and other unusual findings for no apparent reason. We verbalized our suspicions to the attending physician. A chemical assault was confirmed by toxicology reports finding the presence of phencyclidine (PCP) that was injected into the intravenous line by the child’s father.

“Death, under any circumstance in the pediatric ICU, was always a somber experience,” O’Brien notes: There were those heart-wrenching encounters with devastated parents regarding consent for autopsy, who questioned exactly what the procedure would entail. I found myself inept in formulating a response that was truthful and informative, yet compassionate and sensitive since I had never witnessed the procedure. A day in pathology observing autopsies guided me in subsequent parental encounters. It was also during this period, as a critical care nurse, I experienced cognitive dissonance relative to my scope of practice and death. Critical care nursing is dedicated to the prevention of and intervention in lifethreatening situations. Caring for a patient with a diagnosis of brain death was in direct conflict with this mission. Curious about the feelings of other colleagues, this became my graduate thesis subject matter. Death was a frequent by-product of the active level-one trauma center and knowing the forensic value of a dying declaration and demonstrating competence in standards of evidence

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collection and preservation was unmistakable in certain settings.

4.5.1 FORENSIC NURSES’ ROLE IN IDENTIFYING HEALTH CARE SERIAL KILLERS Special agent Bruce Sackman (2002), one of the key investigators in the Kristen Gilbert case, points to the opening words of then-assistant U.S. Attorney William Welch in his opening remarks at Gilbert’s trial in November 2001: It was a cold chilly day. On Ward C of the U.S. Department of Veterans Affairs Medical Center there was a different kind of chill that penetrated the floor. It was a deep eerie feeling; patients were dying unexpectedly from sudden cardiac arrest. Three nurses came together and voiced their suspicions. It was every hospital’s nightmare. There was a killer among them, one who coldly and callously killed four men and attempted to kill three others by injecting them with the heart stimulant epinephrine.

Sackman (2002) writes, “Almost identical words could have been utilized in other recent health care murder cases.” He points to a steady stream of newspaper headlines recounting the actions of these killers. Sackman adds, “Few criminal investigators have experience working suspicious death cases at medical centers because very few of them are ever reported to the police.” He adds, “Highly trained medical professionals who have taken an oath to help heal the sick have a difficult time accepting the premise that a fellow medical professional would intentionally kill a patient.” Sackman says that patients rarely question the drugs administered by health care professionals, and family members are loathe to even consider that the person who is entrusted to heal their relative is endangering their loved one’s life. Sackman writes, “So high is the confidence level in hospital staff that family members refuse to believe the cordial nurse or doctor who frequently visited their mom or dad at the hospital may have intentionally caused their death.” Several factors contribute to a lack of timely response to a potential health care serial killer. Sackman says that fear of damage to a hospital’s reputation has a chilling effect on administrators’ willingness to inquire into allegations about their employees possibly committing murder. He adds that, “Rather than conduct a forensic inquiry, hospital administrators rely on peer reviews to determine that the cause of death was probably related to some underlying medical problem in the patient’s history. Autopsies conducted by the hospital are not forensic autopsies, but are conducted to confirm the patient could have died from an underlying medical problem.” Another factor is the lack of medical expertise on the part of many members of law enforcement, hampering a determination of the cause of death and further investigation. Sackman writes, “If a team of physicians has already determined

through peer review that the patient’s death could have resulted from existing medical conditions, why pursue the matter further?” Sackman says that a health care institution is a perfect place for a homicide due to the level of activity of personnel, the amount of chaos present in places such as the ED, the degree of illness in places such as the ICU, and the overall ability for health care serial killers to blend in, have access to potent narcotics, and be able to cover their tracks when they are finished administering their own, potentially lethal version of clinical intervention. “Given these facts, if I were inclined to commit a series of murders, I would be well advised to choose a health care facility,” Sackman writes. “And what better profession to choose than that of a health care professional, one that virtually gives me the legal power of life and death over a person?” He adds, “Working alone on a night shift, I am virtually guaranteed that there will be no witnesses to my crime. My choice of weapons is formidable. There are a number of ‘sudden-death’ chemicals readily available on the ward, including many that are considered undetectable or generally not tested for at autopsy.” Sackman notes that during the course of an investigation, it was determined 40 sudden-death injectibles existed on just one ward. One of the solutions to identifying suspect individuals, according to Sackman, is the presence of a forensic nurse in the health care institution. He explains that these nurses’ medical skills, coupled with their increasing medico-legal skills, are formidable allies in the effort to collect critical evidence and document suspicious or questionable activity as part of their routine nursing observation and assessment. The scene of a suspicious death in a health care environment is most always the patient room, and the portal of entry of a lethal substance is usually an IV line or a feeding tube. Sackman writes, “In the case of sudden unexpected death, what happens to these crucial pieces of evidence? Are they discarded as a matter of routine? The first assignment of a forensic nurse should be to ensure all physical evidence is retained for possible future forensic examination. The forensic nurse should ensure all pertinent medical records are secured in a safe location.” Sackman explains further that in cases of sudden, suspicious deaths, extended periods of time might pass before investigations are conducted or law enforcement authorities are contacted. He states, “If suspicion only arises as a result of a pattern of untimely deaths, then it can be years before law enforcement is contacted. A review of the case early on by a forensic nurse will help ensure that a timely and correct decision regarding outside referral will be made.” Sackman says that a forensic nurse’s familiarity with the medical record is key to any investigation. “It is important the forensic nurse begins a review of the patient’s treatment records. This nurse must have access to all medical records, including those of the pharmacy service, any correspondence between the patient, patient’s

Forensic Issues in the Clinical Setting

family and the medical center and its personnel.” He says that the forensic nurse, in acting as a liaison between the health care institution and law enforcement, might be asked to review the medical records of other patients that were treated in the same ward or by the same health care professional under question. A nurse’s familiarity with the medical record can assist criminal investigators who have little or no experience in reading a chart, and are unaware of its contents and significance, especially if a critical component of the medical record is missing or incomplete. Sackman writes, “The investigator faces a considerable learning curve when first confronted with a medical suspicious death . . . Cops and prosecutors need a competent guide and interpreter to assist them in their journey through this maze of science and protocol. There is simply no one better suited for this task than the forensic nurse.” Sackman explains that forensic nurses are able to guide investigators through the maze of hospital regulations, numerous quality-of-care issues, and daunting medical procedures and medical terminology: The forensic nurse also has the important skill of evaluating the quality of care given a patient from a nursing perspective. This service cannot be understated. Nurses often reflect upon patient care from a different perspective than physicians or technicians, noting improprieties and spotting errors that other medical professionals miss. Forensic nurses are knowledgeable about drug interactions and the evaluation of prescriptions. All these skills are essential to the investigative team.

Sackman emphasizes that in many cases, the activities of health care serial killers were discovered by fellow nurses who “suspected wrongdoing on the part of a coworker and alerted management,” Sackman writes, although, “unfortunately, management’s initial medical review, absent training in forensics, usually found insufficient evidence to pursue the case.” Sackman is adamant about the many important contributions forensic nurses make to the medico-legal process. He observes, “Forensic nursing is still a relatively new and underutilized discipline. Health care facilities should waste no time in establishing this practice. It is simply what is most needed today to forge the link between medicine and investigation.” Sullivan (in press) explains that there are several causes of what she describes as “caregiver malfeasance.” She writes, “The reality is that most medical facilities across the country are in a crisis mode when it comes to who provides hands-on patient care and how well it is accomplished.” Sullivan points to hospital wards that are overflowing with critically ill patients: A high patient census with equally high acuity levels combined with fewer licensed registered nurses to share the workload makes for a dangerous situation . . . Addi-

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tionally, some new applicants are not always completely honest with background histories, and screening efforts do not always catch the discrepancies. Further, there is an overall failure to discipline or terminate marginal employees, and because of short staffing it is often felt that a “warm body” is better than nobody showing up for work.

Sullivan says these factors set the stage for the entrance of an individual who does not have the best interests of patients at heart. “History has certainly shown that individuals such as former doctor Michael Swango, former nurse Gilbert, and many other former licensed health care professionals who have been successfully prosecuted for criminal acts against patients have taken advantage of these dynamics. These are additional reasons to increase the number of health care providers who are indoctrinated in forensic science in hospitals and clinics.” Pasqualone cautions that there is no blanket approach to identifying perpetrators of killing sprees or a lone incident, in the clinical setting. “All of these kinds of scenarios must be examined on a case-by-case basis,” she says: In the case of serial murders, mercy killings, health care workers who kill, many of them aren’t recognized for what they are when they are happening. Unfortunately, you sometimes recognize suspicious events only after a number of them occur because you see a pattern emerge. Then you start observing your suspect more closely. The trick is to try to get the authorities involved without letting your suspect know that you are suspicious; then, depending on how this person is killing his or her patients, you must collect whatever you think the weapon might be—the syringe or the drugs, or whatever it may be. In the Kristen Gilbert case, nurses actually retrieved the empty drug vials from the trash, but they didn’t get the authorities involved soon enough. They collected the evidence but they failed to establish proper chain of custody; so although it could have been considered hard evidence, it could only be viewed as circumstantial evidence. At least they could reconstruct various events when they collected this evidence, and that’s what created the index of suspicion. But if you suspect that on the spot that one of your colleagues is doing something wrong, you must treat the evidence as exigent; you have to grab it immediately, whatever it is. If something gets thrown into the sharps box, you grab the whole sharps box as evidence; you allow the criminal investigators to sort through it—you don’t retrieve it out of the box yourself.

4.5.2 THE VA’S RESPONSE TO HEALTH CARE SERIAL KILLERS VA hospitals have been the setting of a number of highprofile cases, such as the Kristen Gilbert murders explored earlier, and the killing spree of physician Michael Swango, who might have been one of the most prolific of all known or suspected health care serial killers. A former doctor

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who might have killed as many as 35 or more people in a 15-year poisoning binge, Swango left a trail of suspicious deaths on two continents as he hopped from job to job. “Instead of using his medical license to become a healer, Swango embarked on a career as a killer,” U.S. Attorney Loretta Lynch was quoted as saying in the New York Daily News on July 12, 2000, a day after he was indicted for three deaths at a Long Island hospital. “He used his skills to search for victims and take their lives,” she added. Swango had been accused of injecting lethal doses of drugs into three critically ill patients at the Northport Veterans Affairs Medical Center in 1993. He had been indicted for these killings just days after being released from federal prison after serving two years for lying about his criminal record. At the time, criminal investigators and prosecutors were scrambling to build a case against him in connection to 32 other murders. Despite a 1985 conviction for poisoning six coworkers when he worked as a paramedic in Illinois, Swango managed to secure positions at several hospitals in South Dakota and New York, all because employers failed to check his background. Called a “charming, pathological liar,” Swango talked his way into a medical residency program, neglecting to mention that his medical license had been suspended due to a former conviction of a bar brawl. He was fired, hired, and roamed several continents as he continued to care for and kill patients over the course of a number of years. Following a lengthy legal course of investigations, indictments, and sentences, Swango was finally convicted on three deaths at the VA facility and was sentenced to life in prison. For a complete look at the Swango case and other health care serial killers, go to www.crimelibrary.com. With so many cases unfolding within VA hospitals, the government began to crack down on certain loopholes that facilitated these kinds of crimes. In August 2001, a number of representatives from the Office of the Medical Inspector (OMI) and directors of various VA facilities gathered in Phoenix for a conference, coordinated by Mary Sullivan and her colleague Barbara Spence-O’Donnell. The conference was titled, “Death Investigation, Adverse Patient Events, and Evidence Collection in the Hospital Setting.” During a panel presentation, “A VA Management Initiative and an Emerging Role for Forensic Nursing: Improving Patient Safety by Responding to Suspicious Adverse Events,” four representatives from the Veterans Health Administration discussed how to respond to an increasing number of suspicious events in the health care environment. The panelists were Richard Sorenson, special assistant to the medical inspector; Gary Campbell, then-director of the Harry S. Truman Memorial VAMC in Columbia, Missouri; Mary Dowling, former director of the Northport VAMC; and William Boutelle, MD, thenchief of staff of the Northampton VMAC.

Forensic Nursing

The VA serves close to 4 million veteran patients and more than 350,000 nonveteran patients in a mammoth health care system that has an average daily census of almost 57,000 patients. To respond to an increasing number of suspicious adverse events in VA facilities, in August 2000, the OMI created a working group to focus on the essential elements of investigating suspicious deaths, including identification of cases, protecting evidence at the scene, and developing policies and procedures to address these kinds of medico-legal cases. The common thread of the OMI’s focus was that patient care is paramount and that the safety and security of both patients and staff members was vital to all aspects of VA facility operation. Sorenson explained to the Phoenix conference attendees that the working group had identified several key measures in the identification of suspicious deaths, including establishing definitions of reportable deaths and suspicious events related to existing policies, as well as steps personnel could take to preserve the physical integrity of the death scene, to prevent further disturbance of the crime scene, and ways to maintain the integrity of all medical devices, biologicals, instruments, tubing, supplies, and other medical paraphernalia associated with the clinical setting. He added that personnel need to be alert to the possibility of suspicious, adverse patient events, and that first responders to the scene should provide care if appropriate, notify the authorities, observe the patient and the surroundings, report any alteration to the scene, and notify the medical supervisor on shift. In the same manner, the OMI identified ways that VA police and facility administrators could further protect the scene and facilitate investigation. Sorenson added that forensic nursing was emerging as a way to supplement and contribute to the investigation of any adverse patient event. During the 2001 panel, Gary Campbell reported that there had been an increase in the number of cardiopulmonary codes identified by his facility’s CPR committee, as well as an increase in the number of patient deaths on one inpatient medical and surgical ward in the summer of 1992, the same time period when an allegation of patient abuse had been filed against a registered nurse. Campbell said that a board of investigation was appointed in September 1992. The board members conducted an internal review of codes and deaths at the facility, as well as a statistical analysis that suggested that the deaths were not occurring by chance. Employees who had learned of this internal audit had alerted the media, and Campbell reported that a media crisis had developed rapidly. A joint investigation by the VA Office of the Inspector General (OIG), the FBI, and the U.S. Department of Justice ensued, followed by the exhumation of the bodies of 13 patients. The VA Inspector General for Health Care Inspections reviewed statistical information, and allegations of obstruction of justice and a cover-up were bounced around. A special inquiry by the OIG was

Forensic Issues in the Clinical Setting

launched, followed by congressional oversight subcommittee hearings and a wrongful death civil lawsuit filed against the U.S. government. A dispute resolution specialist undertook a program review and a site visit regarding certain staff members who had identified themselves as whistleblowers, and a review by the Government Accounting Office (GAO) was conducted. During this lengthy process, Campbell said, a number of internal processes were in place, including ongoing quality assurance reviews by various committees, occurrence screening by registered nurses use 100 percent of the time in all deaths, mortality data tracking and trending, and all unexpected deaths forwarded for peer review. According to Campbell, corrective actions included revising an autopsy policy to request autopsy on all deaths, tracking mortality and code data by unit every month, establishment of a hospital peer review board, and an overall sense of heightened awareness created among staff members. The facility established care teams to follow every VA patient through his or her continuum of care, and implemented a patient safety reporting system. Campbell added that the investigation of adverse events should be “timely and as broad as possible.” He acknowledged that there is a tendency for disciplines to “protect their own,” leading to communication breakdowns and delayed decision making. He also stated that facilities must establish “a culture of patient safety” and create “a sense of openness regarding the reporting of unusual or suspicious events.” Also at the 2001 conference panel, Mary Dowling reviewed events surrounding the Michael Swango case and suggested areas of system evaluation and change when responding to adverse patient events. She advocated for a stronger system of employee background checks, a system for addressing gaps in the review process, better training for all department personnel who might come into contact with adverse-event cases, and stronger quality assurance measures. In his panel presentation, Boutelle explained that a delicate balance exists between patient safety and the rights of individuals, and that all adverse patient events must be taken seriously, documented, and investigated in a timely and efficacious manner. He added that leaving a paper trail is better than relying on memory, and the need to communicate effectively among all disciplines of a facility is paramount. Even as the U.S. government was wrestling with a seemingly alarming outbreak of adverse patient events and suspicious deaths in its government-operated health care facilities, a movement of a different kind was slowly taking shape. One nurse at the Carl T. Hayden VA Medical Center in Phoenix, Arizona, began to see how clinical forensic nursing could play an important role in the identification and investigation of adverse patient events. Mary K. Sullivan, MSN, RNC, CARN, was advocating

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the role of the clinical forensic nurse for the VHA health care system. Sullivan (in press) writes, “In some instances, this nurse will work as a member of a multidisciplinary team consisting of administrative, law enforcement, or legal personnel to provide essential subject matter expertise in cases involving suspicious, unexpected patient death or other sentinel events that have occurred in a health care facility.” Sullivan points to research conducted by Dr. George Wesley of the VA OIG, who demonstrated the link between clinical QM activities and forensic medicine and nursing. In a review conducted by the Office of Health Care Inspections of more than 1,000 cases spanning slightly more than a decade, numerous forensic issues emerged, including patient abuse and neglect, assault, suicide, homicide, medication or delivery system tampering, improper medication administration or error, and medical equipment or device tampering. As a clinical forensic nurse coordinator for the U.S. Department of Veterans Affairs, Sullivan continues to advocate for forensic nursing in general and specifically, for the presence of clinical forensic nursing services in VA health care institutions. Not only can they protect patients, they can also protect the health care system, a win–win situation as she sees it. Sullivan, a graduate of Creighton University, draws from extensive experience as a psychiatric nurse. Up until her clinical rotation in psychiatry, she says she struggled to find her place in nursing school; it was as if psych nursing had been created especially for her. “I found that psych nursing was immediately to my liking, and I knew instantly that I belonged there,” Sullivan enthuses. “Psych unlocked the nursing process for me . . . I felt a natural affinity to these patients. From the very start, I was always able to get them to take their meds and do things other nurses couldn’t. It all came very naturally to me, and right out of school, I went into psych nursing.” Sullivan says she attributes to her early success in the discipline to her communication and listening skills: I really listened to my patients, not just heard them, and that’s what made me successful. I like to think that my interpersonal skills and the ability to read between the lines and connect the dots helps me be a more effective nurse. I’m also organized to a fault and I tend to be very good in a crisis situation . . . that’s a good thing because you have the crisis du jour on psych units—there’s always something going on. I like the challenging environment and managing that patient population.

She says psych nursing is not for shrinking violets, nor is it an appropriate setting for someone who is unable to make quick and effective decisions:

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I learned to think on my feet, to make quick, accurate assessments. I was amazed by how fast I could actually think—you don’t really know what you can do until you actually have to do it. One time you might feel like you’re simply lucky, but when you succeed consistently, you become confident in your skills. You don’t stress about stuff before it happens because you’ve already demonstrated that you can function well. You must have quick thought processes and be able to reach conclusions swiftly and succinctly. These are skills that you have to develop, as you can’t really learn them from a book. After all, there is no way that you can capture mentally ill people in a textbook; you have to experience it for yourself. It’s a whole other world in a psych unit.

Sullivan acknowledges the challenges of caring for mentally ill patients, but she says nurses take them in stride. “It goes with the territory. Everyone prefers a quiet shift, but if something is going down, it’s always better to not only be confident in your abilities to manage the situation, but to be backed up by a really good team of co-workers. In a crisis on the unit, you don’t need a lot of talking to get something done—you simply look at each other and you know what needs to be done. It’s instinct, it’s silent communication among competent team members.” In an environment that treats the mentally ill and incapacitated, as well as in a setting that can foster malfeasance, Sullivan says a nurse must constantly be on his or her toes, ready to respond in an appropriate manner consistent with good nursing practice. “Yes, your patients may try to play and manipulate you, but an appropriate response comes with experience. You make good eye contact with your patients, and you are always thinking about your safety and the safety of your patient. Patients want to feel worthy, to feel understood,” she says. “When you are on the same unit every night behind locked doors with the same patients, you start feeling like a family, actually, boundaries and all.” She adds that psych nursing has contributed to her sense of personal well-being. “I have realized how fortunate I am to have a life that is fairly under control, but I have also realized that as humans, we’re all extremely frail—how easily one day you can be squared away and the next day, you’re not.” Despite years on the job at VA facilities in Kansas City, Missouri and in Phoenix, Sullivan says she was oblivious not only to the inner workings of the government, but to how forensic principles could be applied to patient care. In just a short time, Sullivan would find herself in the midst of an opportunity to learn both from the inside out. She recalls: I can tell you exactly when all the forensic stuff hit me. I was married to a detective working with homicides and sex crimes. He often brought his work home, and I often

said, you know, a nurse could do that for you, or a nurse can get in there and find that out. That was in 1990 or 1991. Every time he would have a problem with a case, I wondered, “How would I handle that?” In 1994, the Journal of Psychosocial Nursing produced a forensic issue and after reading it, I thought, “This is for me.” I thought that nursing fit so well with forensic thinking and processes, and, complementing the work of law enforcement; my husband agreed with me, but he never thought it would go anywhere. In the early 1990s, things started gelling for me forensically, but before then, I never heard the word forensic, and never thought about it until I related it to law enforcement and began listening more closely to my husband. I was working things out for myself, and it was so exciting to discover that there was a whole slew of nurses who know this stuff.

Sullivan continued to work as an inpatient psych nurse and charge nurse on the evening shift at the Phoenix VA, and in 1994, she discovered the IAFN: I joined immediately, did my homework, and became familiar with every possible facet of forensic nursing. Then one of the people in the organization said, “Why don’t you look into the sexual assault examiner training program? Do you think the VA would be interested in that?” I didn’t know, but I certainly was, so off I went to San Diego to be trained by Diana Faugno. It was an awesome training session, six straight days, with classes often going until 10 p.m., but we loved it. We had several groups in the classroom; the nurses, a few physicians, the police officers, and some who I considered social workers who turned out later to be victim advocates. We all spoke different languages; we all were absorbing the information differently. On Monday morning, no one really talked to each other, by Friday we were all speaking the same language and I thought this process was fabulous. But on Monday morning, when I was sitting there in the first row, listening to the speakers and being totally in awe of them, I knew right away that a sexual assault agenda alone was never going to fly in the VA. It was not going to work as a program because it wasn’t broad enough to meet the mission statement of the VHA. But as we were taught about the head-to-toe physical assessment, the interviewing process, the evidence collection process, things started to click in my brain. As nurses, we do all of this anyway, so forensics have to be applicable to all nurses and to all patients. I mean, all nurses conduct physical assessments and listen to patients and hear the stories right from the get-go. So I thought, “I’m going to get forensic nursing into the VA, but it can’t be as a sexual assault nurse; it has to be as a generalist so that we can apply these principles across the board.”

In 1996, Sullivan gave her director a proposal:

Forensic Issues in the Clinical Setting

I had five meetings with him, and finally, during the fifth meeting he said suddenly, “OK, let’s do this.” In fact, he not only gave me permission to put my own team together and train them, he gave me the budget to pull in trainers so that I could replicate the full training experience I had in San Diego. He also gave me two rooms in the ER to outfit as forensic exam rooms, as well as funds with which to buy forensic-related equipment. He gave me a lot of freedom to develop this forensic nursing program. To this day, I don’t know what exactly convinced him to give me the go-ahead.

However, Sullivan says, problems popped up: We wanted to offer sexual assault exams to the community for free, as the federal government cannot make money off of the community. But, we are not supposed to lose money, either. So somehow, in taking care of the veterans, we were going to do this as a community service 24/7 with our 11 sexual assault nurses and brand-new equipment. But due to county politics, it wasn’t going to work. Our county attorney’s sexual assault bureau had other ideas about making money and went with a private-sector provider instead.

Feeling a bit wiser after the experience, Sullivan says she continued to approach sexual assault from new perspectives in an effort to serve the broadest range of patients possible. “We had all this talent in the VA—11 nurses, and we needed to make the most of their special training.”

4.5.3 THE VA CONSIDERS THE ADOPTION OF FORENSIC NURSING Sullivan takes a deep breath before plunging into the story of how forensic nursing was embraced tentatively by one of the country’s largest health care systems. She had been asked by longtime forensic nursing proponent Janet Barber, MSN, RN, to ponder a forensic nursing wish list if there were no obstacles to this emerging nursing specialty. “She asked me to write up a strategic plan for implementing forensic nursing into the VA, so I did, and sent it to her,” Sullivan recalls: Unbeknownst to me, Janet ended up taking it to Washington, DC, and it landed in the hands of the Inspector General (IG). In the meantime, I had made a poster presentation at the Association of Military Surgeons of the United States in Irvine, California. I was checking out another guy’s poster and he turns to me, looks at my name tag and says, “Oh, you’re Mary Sullivan . . . I know of you.” So we start chatting, and it turns out he is the medical advisor to the IG, Dr. George Wesley. He says, “I have your strategic plan on my desk.” Here we are, at 9 p.m. at night after a full day at the conference, and we’re both tired, and we say hey, let’s talk about this proposal. He then said, “You really should be involved in the suspicious death medical evidence task force that is being

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organized in Washington.” That’s when he explained it was being formed to address suspicious adverse events and the management of medical evidence in the VA system. My attention had suddenly become diverted from the sexual assault project; and I now realized I had a vehicle with which to apply forensic nursing across the board, for all nurses and to all patients. I knew there was now a reason to step out of the sexual assault role and apply our forensic training to a much broader universe.

Sullivan says soon after, she and a colleague coordinated the aforementioned August 2001 clinical forensic nursing conference in Phoenix. “The event was attended by many high-profile people from Washington, and we were able to demonstrate our knowledge about suspicious deaths and adverse patient events, and the application of forensic nursing to these incidents,” she explains. “Three of the original 11 team members were selected to serve on the OMI’s medical evidence task force, so essentially, we were going back and forth to VA headquarters in Washington, DC for two years. We used every opportunity to educate anyone who would listen in VA headquarters about forensic nursing.” Although it was a slow process, Sullivan says it paid off in significant dividends eventually. “They demonstrated curiosity and fear; initially, they didn’t want anything to do with us,” Sullivan recalls, chuckling with laughter: They thought to themselves, “Who are these people?” After all, we were field personnel, staff nurses, total peons, and they were all the top leadership in the VA. Some of them embraced the concept of forensic nursing, seeing it as a gift to the VA system, while the other half said, “These people are out of their minds. It was an honor and a thrill to be on the task force, because, and I can’t stress this enough, we were little people at the very big table. Most of these folks had no clue about forensic principles such as chain of custody or evidence collection. We wanted to continue to reinforce that forensic nursing bridges the gap between medicine and law enforcement. We’re trained in evidence collection, we understand chain of custody, we know how to freeze a crime or death scene and we know how to preserve it until the right people arrive; we know how to take statements, and we know how to document. The people on the task force weren’t sure what we were talking about half the time because we were talking medicine and nursing, and the other half was talking law enforcement—and the administrative people were in the middle. There is also a huge application of forensic nursing processes to events that are not criminal in nature. Anything that has even a remote chance of having legal implications should require a clinical forensic nursing presence.

Sullivan reports a slow, gradual understanding and acceptance of certain medico-legal concepts by the VA since the original task force meetings in 2000 and 2001:

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It’s 2005 and we’re still in the process of convincing them. The directive that came out of that early task force did not pass, as every department in the VA signed off except one. But our work was done; that task force was a direct response to recommendations made by the IG from the health care serial-killer investigations. So in the meantime, we held the Phoenix forensic nursing conference, and we kept educating people at every turn. We know that we don’t need a directive to deliver good patient care or to improve nursing practice.

Sullivan says she is encouraged by the open reception she received from the VA’s chief nurse executive, Cathy Rick. “She is very supportive and has always given me her ear. She kept giving me opportunities to talk about forensic nursing, and I took her up on every one of them.” In 2003, Sullivan again presented a revised strategic plan for forensic nursing, and it was reviewed by the National Nurse Executive Council, the power-base through which all nursing business is evaluated and approved in VHA. “We’re working on the first phase of education and training, what clinical forensic nurses are, and what they do. The first goal is increasing awareness among all clinicians about what constitutes medico-legal significance in the health care setting.” Sullivan believes that because of the size of the VA’s size nursing force, the location of its facilities in nearly every kind of community, and its sizable patient population served, it is the perfect health care entity in which to implement forensic nursing services. In time, the VHA could set an example for private-sector health care systems to follow. “The VA is all over the country, in all settings, whether rural or urban, with different personalities, politics, and patient needs, so if forensic nursing can work there, it can work anywhere,” Sullivan emphasizes. She says she has been explaining to the VA that forensic nurses embody many different roles, as death investigators, as SANEs, as legal nurse consultants, and as forensic psychiatric nurses, to name a few, and that they practice both in the clinical setting and in the community: I have suggested that VA nurses are practicing forensic nursing outside of the VA, and that we need to bring this expertise in-house for the benefit of our veterans. I have been approved by the NNEC to bring together qualified nurses with a forensic background in a work group to identify the aspects of forensic nursing that can be applied immediately, as well as identify long-term goals, and education and training needs of other nurses who want to be forensic nurses in the VA system. At the time of writing, we are in the process of our work, and it is moving forward. Clinical forensic nursing is applying forensic nursing to the existing patient care process. There are two groups of nurses who need forensic awareness. First, the frontline personnel working directly with patients. In this frontline

group, there are the nurses who do not have the time, money, inclination, or energy to go back to school specifically for forensic training, but they still need information about forensic principles. The other group of frontline nurses is those who do not want to pursue further training and education and eventually put this expertise into patient care delivery. Those nurses who already have a forensic background, I would hope, would be eager to serve as preceptors. Together, these nurses will open others’ minds so they can see that forensic nurses have so many skills to offer health care institutions and communities, from sexual assault nurse examination, to death investigation and nursing jurisprudence and so much more.

Sullivan says that it is equally critical to reach QM personnel in health care facilities. “These nurses are like the cold case investigators,” Sullivan explains. “There are situations in the hospital where the evidence is gone, nobody wants to talk to you, and you have a hard time coming up with a recommendation for change because you don’t have the evidence, facts, or data.”

4.5.4 THE ROLE EXAMINER

OF THE

CLINICAL FORENSIC NURSE

Sullivan believes passionately in the role of the CFNE in any health care setting, as a trained individual well versed in handling tricky, potentially medico-legal events such as codes and unexpected deaths. Sullivan (in press) writes: The clinical forensic nurse provider would respond to all codes called whether the patient survives or not. This nurse does not participate in providing treatment during the code, but instead monitors events and accounts for all treatments provided. The nurse ensures that EKG strips are preserved along with the sequential records of medications, airway management, and other interventions such as defibrillation. In addition, all circumstances that immediately preceded the code are documented, including the names of family and staff members present before and during the code. A standard set of laboratory specimens are typically collected, especially if the patient does not survive the resuscitation attempt. This information is archived and if a suspicious trend is later identified, more complete information is available for root cause analysis or other investigation processes.

Kathleen Brown, RN, PhD (2003) writes: Documentation of any injury created by a treatment process is also helpful to law enforcement. If the victim does not survive, leaving tubes, catheters, and any other devices used for treatment in place assists law enforcement in differentiating injuries created by medical personnel from injuries created prior to treatment. Collection and preservation of forensic evidence in a health care setting assists

Forensic Issues in the Clinical Setting

law enforcement and, therefore, assists the victims of the crime who are seeking justice.

Sullivan adds that forensic nurses might also be able to respond to bomb threats, fire alarms, infant abductions, environmental security breaches, or hostage scenarios. Another critical domain of the CFNE is clinical deaths. As envisioned by Sullivan, the CFNE would respond to every patient death, whether expected or unexpected. She says that ideally, the CFNE would document the circumstances of each death, collect laboratory specimens, note the last physician order changes, medication and treatments received in last 24 hours, any visitors, and other pertinent data. Sullivan writes, “If a suspicious trend is later identified, more complete information is available for root cause analysis or investigation.” She adds that if the death is suspicious or unexpected, the CFNE can “freeze the scene until further consultation with the supervisor or law enforcement. Fortunately, these events happen rarely, but it is important to have someone who realizes what may be vital evidence and is instrumental in maintaining the integrity of this potential crime scene.” A third critical purview of the CFNE is the change of shift at a health care facility. Barber has stated that the time frame between the change of shifts provides an ideal “window of opportunity” for criminal activity ranging from stealing narcotics, to tampering with life-support equipment or IVs, to in some way attempting to harm a vulnerable patient. There are numerous dynamics at work during a change of shift, including health care personnel who are going off shift disengaging from their responsibilities too soon, and personnel who are coming on to their shift engaging in work only after the preceding shift has departed. Additionally, Barber says that health care providers might use the shift change as an opportunity to engage in social interaction rather than professional communication. Barber adds that personnel who are just starting their day might be preoccupied with “nesting” activities, including getting coffee, or arranging one’s work tools and supplies. She also says that at the change of shift, priorities can become “fuzzy,” with documentation and oral reports taking precedence over continuing care activities. Finally, there is a tendency for health care providers to make erroneous assumptions about what their colleagues will do or have done, increasing a margin of error for the completion of critical clinical tasks. Sullivan (in press) writes: Patients as well as visitors are often aware of the confusion and chaos that may occur at change of shift, and some may take advantage of these opportunities to engage in behavior not conducive to the health and welfare of other patients on the unit. Those caregivers who have ideas other than providing health care on their minds will also realize

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that the change of shift provides an optimum time for inappropriate, illegal, or otherwise dangerous behavior. The clinical forensic nurse provider may encourage and reinforce the heightened awareness of all staff at these particular times.

O’Brien recalls a change-of-shift incident that has stuck with her: The day my ventilator-dependent patient was disconnected from respiratory support while I participated in change-of-shift report was suspicious and could not have been accidental. During report, I focused on a distant but constant alarm, which I immediately recognized. I rushed to a private room, finding the door only slightly cracked open and the curtain pulled around the bed. The machine was connected to the endotracheal tube but not ventilating, and appeared to be malfunctioning. The visitor chair, occupied 15 minutes earlier by the patient’s daughter, was now empty and she was nowhere in sight. The patient was in acute distress and as resuscitative efforts ensued, I frantically tried to determine what had gone so terribly wrong. Just prior to report, a physical assessment had been performed with stable findings and ventilator settings double-checked. The patient had been resting comfortably in the company of his daughter. I instructed her to call if anything was needed and said I would be in report. As other team members responded to the code, it was soon determined the ventilator was unplugged from the wall outlet behind the headboard. The prospect that his daughter was involved or responsible for his expiration left me stunned, saddened and feeling professionally violated. While I empathized with the family’s plight, should I have been more suspect of a family distraught and divided over a loved one’s ventilatordependent state? Or did someone unauthorized enter the room, a person who was familiar with unit routines, and aware that staff would be clustered in report and not in close proximity to the room? Could the plug of this older model machine just happen to fall out of the outlet causing it to lose power? For weeks thereafter, I searched for clues I might have missed and struggled with feelings of guilt in failing my responsibility to keep my patient safe from harm, even if that included members of his own family, which was an inconceivable thought to me at that point in my career.

Barber says that due to the high number of incidents occurring during the time of the health care “changing of the guard,” the role of the forensic investigator is to conduct a root cause analysis (RCA) through which the nurse reconstructs the event in the context of the health care facility’s schedule of activities, and using tools that pinpoint the personnel present and various related timelines. Key documents to obtain early in the discovery of a suspicious event include medical records, personnel schedules, pharmacy orders, sign-out sheets for equipment and

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Forensic Nursing

supplies, supervisor’s report, housekeeping log, telephone and/or e-mail log, names and conditions of patients on the unit at the time of the event, records of charges to patients and other invoices, a list of equipment and supplies in the patient’s room, monitoring records from bedside recording devices, and any appropriate photo-documentation. According to Barber, risk-reduction strategies for the change of shift include radio-frequency tracking technology, which records personnel’s activities in the patient’s room and their interfaces with medical equipment; pointof-care data entry systems that allow personnel to spend more time on meaningful clinical activities in the patient’s room; technology-enhanced aids such as bed-exit alarms and restraint-monitoring devices; and personnel performing walking rounds, where outgoing and incoming health care providers can meet to exchange their reports at the bedside to “clarify, rectify and validate care components,” Barber says. Regarding RCAs, Sullivan (in press) writes: I see the CFNE as an essential part of the hospital team with the responsibility to evaluate and perform the root cause analyses of adverse patient events. Adverse patient events range from those causing minimal concern to extremely serious action, but the vast majority are not criminal in nature. However, precise identification, collection, and management of facts, data, and medical evidence are critical, criminal or not. I am referring to ensuring a higher level of quality patient care and accurate delivery of our services. It is our duty as health care providers to be accountable for our actions and to ensure a safe environment for our patients.

Sullivan asserts that the costs associated with hiring a CFNE would be quickly recouped in terms of litigation, settlements to families and insurance reimbursements. The positive outcomes in increased accuracy of in the delivery of patient care services and more cost-effective investigation processes realized from utilizing a CFNE could be easily tracked and quantified. Research utilization information would further indicate additional areas that could be positively impacted by the CFNE. Still, the bottom line remains: There is no price that can be placed on the increased feeling of safety and satisfaction of patients who count on us for competent delivery of care or for lives we may save. Sullivan says: Code events are situations where a forensic nurse would be essential. For example, have a forensic nurse arrive at every code and assess the situation from a forensic nursing point of view. This would include looking at events before, during and after the code, retrieving data, investigating what happened, determining who visited the

patient, did they just eat or drink something, etc. After the code, the forensic nurse would look everywhere, including in the trash for anything unusual, and would also account for any medications administered. All data would be placed in a separate report, turned into the quality management department, and then archived. Data can be trended to see which staff members attended the code, which shifts and units are getting the codes, and other vital information. The same with every patient death . . . page the forensic nurse, who can reconstruct what happened in the 24 hours prior to the adverse event. And if it’s a suspicious event, the forensic nurse may opt to “freeze” the scene, which would be a rare event. It doesn’t necessarily have to be a suspicious or criminal event to warrant data collection. I remind people that being forensic-minded is really being medico-legal minded, which is also a risk-management strategy.

The concept of living forensics, one of the most unsung components of risk management ever, was a challenging one for the VA to grasp initially, Sullivan says. She acknowledges the significance of the VA’s initial steps toward the implementation of forensic nursing in its facilities, and says she is proud that her health care system is leading the private sector in this regard: We will lead and we will benchmark. The private-sector health care system has to worry about bad publicity caused by adverse events, or the facility closing, or taking a major financial hit. If the hospital is in a small community, it could lose business, health care providers don’t get paid, and patients don’t receive care; or there are insurance issues with which to contend. There are many reasons why private-sector hospitals don’t want their business aired on the evening news. At the VA, we’re an open book, and we are in a very good position to be proactive about this. There is no other health care entity that has taken this bull by the horns. It’s simply a more accurate, more precise delivery of care, and if we catch any funny business in the meantime, then good for us. The VA answers to the taxpayers and to Congress, and we have oversight by the Inspector General. We have every reason to be proactive. If I were in the private sector, I would never have this opportunity, which is another reason why I love being a VA nurse.

What might be most significant is the vast number of nurses who are potentially impacted by the VA’s interest in forensic nursing. The VA currently employs approximately 60,000 nurses, according to Sullivan, and if half that number of nurses is interested in forensic nursing principles, that is 30,000 forensic nurses who will one day be looking after the welfare of patients and victims of violence everywhere.

Forensic Issues in the Clinical Setting

4.6 QUALITY IMPROVEMENT AND RISK MANAGEMENT In many ways, forensic nursing serves as a key quality improvement and risk management tool because it helps hospitals identify patient populations and clinical situations that pose medico-legal questions to answer and issues to resolve. Janet Barber says she sees the private health care sector fashioning itself after the government health care sector in the future as a way to cultivate greater transparency of wrong-doing and to foster increased accountability: With more people on Medicare and Medicaid, and with an increasing number of people on national health care plans through the military, I think the general public will eventually have the same kind of scrutiny of its hospitals as government facilities. The same goes for making a case for quality improvement in health care. If a health care institution can reduce its risks, that certainly demonstrates to the public that it is a safe place to be, and that your health care processes are of the highest quality. Within the concepts of quality assurance or quality improvement, a health care facility looks for its weak spots and fixes them. And that is precisely what forensic nursing is doing . . . it is looking for the weak spots, identifying them, handling them, and then putting into place solid solutions that become ongoing and a part of everyday practice at the facility.

Sullivan (in press) writes, “The forensic nurse specialist is adept in performing forensic medical record reviews and is the appropriate liaison to hospital risk management and legal personnel. The forensic nurse specialist is an ideal adjunct to quality management with regard to analyzing trends and performing root cause analyses to adverse patient and sentinel events.” Barber (2001) adds that a clinical forensic nurse specialist assisting the quality improvement or risk management staff or other authorities in an investigation can reconstruct the event within the context of the hospital’s schedule of activities. She notes, “Tools that assist in pinpointing personnel presence and timelines of activities include the following: medical and pharmacy records, equipment sign-out sheets, housekeeping log, e-mail files and computerized medical record entries, records of charges billed to patients, monitoring records from bedside recording devices, and the supervisor’s report. Others include the personnel schedule or time clock records and telephone paging logs.”

4.7 VIOLENCE IN THE HEALTH CARE ENVIRONMENT Violence in almost any occupational setting is of concern, but few workplaces are as susceptible to disturbances as health care settings, the scene of trauma, chaos, and anger.

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The tables sometimes turn, with patients inflicting harm and injury on their health care providers. A study published in the February 2005 issue of Annals of Emergency Medicine found that verbal threats, physical assault, and even stalking, are not uncommon workplace problems for emergency physicians and other personnel. Of the 171 respondents surveyed, 131 (76 percent) reported experiencing at least one violent act during the previous 12 months. Three quarters (74.9 percent) of respondents said they had encountered verbal threats; nearly one third (28.1 percent) indicated they were victims of physical assaults; 11 percent indicated they were confronted outside the emergency department, and 3.5 percent reported experiencing stalking events. “Emergency departments, by their very nature, are high-stress places for both the patient and staff,” said lead author Terry Kowalenko, MD, of the University of Michigan Medical Center in Ann Arbor, Michigan. “Add to that mix patients who are intoxicated, in a state of drug withdrawal, suffering from delirium, or have psychiatric problems that may make them more prone to violence and you have a potentially volatile atmosphere.” Despite the large majority of emergency personnel experiencing a violent act, 80 percent said they are only occasionally fearful of workplace violence, and a little more than 9 percent said they were frequently fearful. In response to their fear of violence, 42 percent of emergency physicians report that they did obtain some sort of protection, including obtaining a gun (18 percent), a knife (20 percent), or a concealed weapon (13 percent) or carrying mace (7 percent) or a club (4 percent). However, most (31 percent) used a security escort as their method of choice for personal protection. The survey also found it is not just patients who are violent. Of the emergency physicians who reported experiencing physical assaults, 89 percent came from patients, 9 percent from family members, and 2 percent from friends of patients. Drugs and alcohol appear to be the major factor in the most violent acts. Emergency physicians reported that 45 percent of physical assaults occurred with patients who were believed to be intoxicated. Despite the potential for violence in EDs, less than one third (27 percent) of emergency physicians and other personnel report their hospital has permanent security officers assigned to the ED, and 24 percent reported having general hospital security staff that included the ED in their rounds of the hospital. However, the study authors said further research is needed to determine if increasing the presence of security personnel would decrease the violence. Stultz (1996) documented that overall crime in hospitals participating in the 10th annual International Association for Health care Security & Safety (IAHSS) survey increased by 7 percent in 1995 versus 1994. On a perhospital basis, five crime categories showed increases:

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murder, suicide, physical assault, sexual assault, and theft. Six categories showed decreases: robbery, arson, burglary, auto thefts, bomb threats, and vandalism. Whereas crime in urban and suburban hospitals in 1995 leveled off after a sharp increase reported for 1994 over 1993, rural hospitals showed a 9 percent increase in crime in 1995 over the previous year. The 1995 crime rate was 11 percent higher than the preceding eight-year average, with physical assault 36 percent higher than the eight-year average, and sexual assault 88 percent higher on a perhospital basis. In “Preventing Violence in the Health care Setting,” Kathleen Brewer-Smyth, RN, PhD, CRRN (2003), a postdoctoral fellow at the School of Nursing of the University of Pennsylvania, describes the hypothetical case of a young critical-care nurse who had been kicked in the face by a disoriented patient while she was attempting to preserve his arterial and central IV lines. Although the patient was unharmed and the nurse was uninjured, her confidence had been shaken, and she wondered what she had done to possibly provoke the violent incident. Brewer-Smyth says that although health care providers cannot avoid potential harm, they can be better prepared to deal with outbursts and threats of physical harm from patients or even coworkers. She writes, “Nurses heighten their awareness and expertise in dealing with violence in their professional settings by learning to identify risk factors and warning signs, and by applying interventions that could shield their patients and themselves from harm.” The hospital, like other occupational settings, can be a turbulent environment. In 1993, a survey of the general public estimated that 2.2 million Americans were attacked at work during the preceding 12 months and that another 6.3 million were threatened. In a 1994 study, one out of 12 human resources managers disclosed that at least one violent workplace death had occurred in their organization within the past four years. Brewer-Smyth says that accurate statistics from health care settings are difficult to obtain due to underreporting. In violent attacks in acutecare facilities, 36 percent to 43 percent of victims filed a report through risk-management tracking systems. “Extra paperwork, time spent explaining the incident, and fear of being blamed are a few of the reasons some have avoided alerting anyone of an incident. Combative, threatening behavior that deescalates and does not result in actual assault may not be reported at all, making the problem seem less significant than it is,” Brewer-Smyth writes. Regardless, a high prevalence of violence has been reported in the health care environment. The National Institute of Occupational Safety and Health (NIOSH, 2002) reports that violence often takes place during times of high activity and interaction with patients such as meal times, and during visiting hours and patient transportation. Additionally, assaults might occur when service is denied, a patient is involuntarily admitted, or a health care worker

Forensic Nursing

attempts to set limits. Violence occurred most frequently in psychiatric and ED waiting rooms, and in geriatric units. Thackrey and Bobbitt (1990) reported that of 122 clinical and nonclinical employees surveyed on medical, surgical, and psychiatric units of a 475-bed teaching hospital, 48 percent reported at least one attack. Carmel and Hunter (1989) reported that an investigation of a state psychiatric hospital disclosed an injury rate of 16 per 100 nursing staff per year and that rate only encompassed injuries that resulted in death, medical treatment, or transfer of the staff member to another unit. Pane et al. (1991) reported that a 493-bed urban university-affiliated hospital experienced 686 incidents of violence in one year, with most situations requiring police intervention. May and Grubbs (2002) described a survey of nurses working in the ED, ICU, and on the general floor in a 770bed acute care medical center in which 88 percent reported being verbally assaulted and 74 percent reported being physically assaulted by patients and family members or visitors. The assaults were perpetrated most often by patients with cognitive dysfunction (79.1 percent), patients with substance abuse (60.5 percent), and persons who were angry because of the patient’s condition (55.8 percent). Weapons also play a part in some violent incidents in health care facilities. Lavoie et al. (1988) reported that almost half of the respondents in a study of teaching hospitals in the United States reported that they confiscated weapons from patients and visitors at least once a month. One ED used metal detectors to seize more than 300 weapons a month. Lanza et al. (1991) discussed various risk factors for health care providers and patients, but did not discover a significant association between violence and personnel’s gender, age, length of employment, history of working with the mentally ill, organizational position, or amount of time spent in certain patient care activities. However, the researchers found that staff who had been assaulted were more likely to be unmarried, and spent more time administering medications, setting limits, and observing and talking with patients. Brewer-Smyth reports that the likelihood of violence in health care settings has also been linked to certain patient diagnoses, work situations, and geographical areas, but cautions that “all nurses need to anticipate trouble by accurately assessing risk factors and changes in patients’ behaviors” that could be triggered by underlying physiological causes such as metabolic abnormalities, drug toxicity, and acute pulmonary or neurological impairment. Brewer-Smyth warns, “Violence may still be difficult to predict when precipitated by situational factors. A patient’s visitor, such as a bereaved loved one or a member of an opposing street gang, may become unexpectedly assaultive in a health care facility. Nurses need to be vigilant for clues that indicate that friction may lie ahead.”

Forensic Issues in the Clinical Setting

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Although no single strategy for the prevention of violence in the workplace exists, Brewer-Smyth states: Employers need to assess the environment’s risks, develop relevant policies and procedures that address prevention and intervention, and monitor the effectiveness of these standards. Employers also need to create an environment of open communication between staff and management that emphasizes the importance of reporting an incident and the actions that were taken. Additionally, employers must recognize that a rested staff which has adequate time away from the work environment is more likely to have the energy and patience to manage difficult patients, family, and visitors.

She adds that a number of studies have demonstrated that better training in violence issues is one step toward taking preventive measures. Health care providers are advised to do the following: •

•

•

Assess the environment for ways to make the health care facility’s physical surroundings more conducive to a pleasant experience. Highrisk areas such as ED waiting areas should be spacious and well lit, with adequate seating and access to refreshments, restrooms, and telephones. Security guards, surveillance cameras, panic buttons with silent alarms, metal detectors, and bulletproof glass might be necessary precautions. Objects that can be used as weapons, such as pictures and tables, should be affixed to the wall or floor. High-risk units should have enclosed nurses’ stations, staffonly restrooms, and emergency exits. Assess the patient population on a unit to identify potentially violent patients and their triggers. Typical triggers include crowding, noise, irritating patients and staff, boredom, unstructured activity, and tasks that a patient might not want to perform, such as physical therapy. Whenever possible, redirect patients’ attention to focus on things that do not agitate them, or take them to a quieter place. Staffing patterns should also be designed to prevent personnel from working alone and to minimize patient waiting times. Rosenthal et al. (1992) reported that when one hospital installed an electronic system that flagged records and alerted personnel to patients with histories of disruptive behavior, and used it with other interventions, violent incidents decreased 91.6 percent. Convey an impression of interest and caring by being cognizant of body language and facial expressions, as well as communicate in an honest and respectful manner with patients, their families, and other visitors. They should also

•

•

control their own behavior and reactions to hostile actions or comments from patients or visitors. Acknowledge a patient or visitor’s frustration at their perceived loss of control over their situation; keep patients and their families informed and involved in decisions regarding their care whenever possible, and respect their right to privacy. Brewer-Smyth writes, “Rigid, unfair, or overly strict rules and regulations, especially regarding visitors, can trigger anger and need to be avoided whenever possible. Maintaining and updating policies and procedures ensures consistency and takes the burden off the staff member for individual decisions.” Ensure staff members’ safety by coming to consensus on what constitutes unacceptable patient or visitor behavior, and being able to recognize it when it occurs, and being able to obtain immediate assistance when necessary. BrewerSmyth writes, “Never attempt to deal with a physically aggressive patient alone. If necessary, remove yourself from danger . . . never turn your back on an angry person, corner an individual, or allow a person to get between you and the door or an escape route.”

The Occupational Safety and Health Act’s general duty clause requires that employers provide safe and secure workplaces for their employees, but recent fiscal constraints might tempt institutions to try to do more with less, often resulting in fewer security personnel available or other means of protection. As a result, an increasing number of health care providers are contending with violence on the job that can in turn trigger fear and anger, depression, sleeping difficulties, headaches, or a desire to leave an otherwise rewarding career. Brewer-Smyth writes, “Although many nurses who have been assaulted have not lost time from work, others have required (time) . . . to fully recover from the physiological, emotional, and social effects of the experience.” Health care providers must report all incidents of violence to their risk management departments, and should consider taking advantage of their employer’s various counseling programs. “Violence may be difficult to predict and prevent,” Brewer-Smyth writes: Sometimes there is nothing health care providers can do to avoid its occurrence, which is why additional research is needed to identify more strategies that can effectively prevent and reduce violence in the work setting. Nurses can anticipate violence and use tested interventions to prevent it or at the least, reduce its ill effects by learning to recognize risk factors and warning signs.

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REFERENCES Brewer-Smyth, K. Preventing violence in the health care setting. Nursing Spectrum. 2003. Carmel, H., & Hunter, M. Staff injuries from inpatient violence. Hosp Comm Psych. 40, 1, 41–46, 1989. Carmona, R., & Prince, K. Trauma and forensic medicine. J Trauma. 29, 1222, 1989. Carr, M. E. Care of the victim of sexual assault. Available online at: http://www.EMedHome.com. 2001. Evans, M. M, & Stagner, P. A. Maintaining the chain of custody: Evidence handling in forensic cases. AORN J. Vol. 78, October, 2003. George, J. E., Quattrone, M. S., & Goldstone. M. The duty to document: What are the limits? J Emerg Nurs. 23, 5, 467, 1997. Goll-McGee, B. The role of the clinical forensic nurse in critical care. Crit Care Nurs Q. 22, 1, 8–17, 1999. Goll-McGee, B., Couto, S., Ferrandi, J., Jankowski, K., Lawlor, J., Luciani-McGillvray, I., & Robertson, M. Forensic nursing process: An evaluation of forensic patients in the clinical environment. Forensic Nurse. July, 2003. Hoyt, C. A. Evidence recognition and collection in the clinical setting. Crit Care Nurs Q. 22, 1, 19–23, 1999. Jones, P. Reaching the elderly through hospital emergency rooms. Aging. Winter, 1991. Keen-Payne, R. Serving as an expert witness in rape cases. Nurse Pract. 13, 7, 59–62, 1998. Lanza, M. L., Kayne, H. L., Hicks, C., & Milner, J. Nursing staff characteristics related to patient assault. Issues Ment Health Nurs. 12, 3, 253–265, 1991. Lavoie, F. W., Carter, G. L., Danzl, D. F., & Berg, R. L. Emergency department violence in US teaching hospitals. Ann Emerg Med. 17, 11, 1227–1233, 1988. Lynch, V. A. Clinical forensic nursing: A new perspective in the management of crime victims from trauma to trial. Crit Care Nurs Clin North Am. 7, 2, 489–507, 1995. Lynch, V. A. Clinical Forensic Nursing: A New Perspective in Trauma. Collins: Bearhawk Consulting Group. 1997. May, D. D., & Grubbs, L. M. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. J Emerg Nurs. 28, 1, 11–17, 2002. Mund, S. More on evidence collection. J Emerg Nurs. 22, 1, 12–13, 1996. National Institute of Occupational Safety and Health (NIOSH). Violence: Occupational hazards in hospitals. Centers for Disease Control and Prevention (CDC), Washington, DC: Department of Health and Human Services. Publication No. 2002-101. 2002. Pane, G. A., Winiarski, A. M., & Salness, K. A. Aggression directed toward emergency department staff at a university teaching hospital. Ann Emerg Med. 20, 3, 283–286, 1991. Pasqualone, G. What’s behind door 24?: An examination of forensic categories among patients seen at a community hospital emergency department. Unpublished manuscript, Fitchburg State College, Fitchburg, MA. 1998. Pasqualone, G. Forensic categories among patients in the ED. Forensic Nurse. July, 2003.

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Reece, R. M. Identifying the abused child in the emergency department. 2001. Available online at: http://www.emedhome .com. Rosenthal, T. L., Edwards, N. B., Rosenthal, R. H., & Ackerman, B. J. Hospital violence: Site, severity, and nurses’ preventive training. Issues Ment Health Nurs. 31, 4, 349–356, 1992. Sackman, B. Profile of a VA serial killer: Red flags for health care inspectors. Paper presented at Forensic Nursing Clinical Update 2001: Death Investigation, Adverse Patient Events, and Evidence Collection in the Hospital Setting, Phoenix, AZ. 2001. Smock, W. S. Development of a clinical forensic medicine curriculum for emergency physicians in the USA. J Clin Forensic Med. 1, 1, 27, 1994. Smock, W. S., Ross, C. S., & Hamilton, F. N. Clinical forensic medicine: How ED physicians can help with the sleuthing. Emerg Legal Brief. 5, 1, 1–8, 1994. Stultz, M. S. Crime in Hospitals 1995: The Latest IAHSS Survey. J Healthc Prot Manag, 13, 1, 1–45, 1996. Sullivan, M. K. Opportunities and challenges in forensic nursing. In V. A. Lynch, Ed., Forensic Nursing in the Hospital Setting. New York: Elsevier. In press. Thackrey, M., & Bobbitt, R. G. Patient aggression against clinical and nonclinical staff in a VA medical center. Hosp Community Psychiatry. 41, 2, 195–197, 1990. Winfrey, M. E., & Smith, A. R. The suspiciousness factor: Critical care nursing and forensics. Crit Care Nurs Q. 22, 1, 1–7, 1999. Yorker, B. An analysis of murder charges against nurses. J Nurs Law. 1, 3, 35–46, 1994.

RECOMMENDED READINGS American College of Emergency Physicians (ACEP). Evaluation and management of the sexually assaulted or sexually abused patient. Dallas, TX: ACEP. 1999. American College of Obstetricians and Gynecologists (ACOG). Adolescent acquaintance rape. Int J Gynecol and Obstet. 42, 209–211, 1993. Ball, G. G. Modifying the behavior of the violent patient. Psychiatr Q. 64, 4, 359–369, 1993. Benak, L. D. Forensics and the critical role of the ER nurse. On The Edge. 7, 1, 20–22, 2001. Blair, D. T. Assaultive behavior: Does provocation begin in the front office? J Psychosoc Nurs Ment Health Serv. 29, 5, 21–26, 1991. Blank, C., & Mascitti-Mazur, J. E. Violence in Philadelphia emergency departments reflects national trends. J Emerg Nurs. 17, 5, 318–321, 1991. Brenneman, K. Forensic nursing teaches nurses to preserve evidence. Boston Bus J. 17, 40, 12, 1997. Burgess, A. W., Burgess, A. G., & Douglas, J. E. Examining violence in the workplace. J Psychosoc Nurs Ment Health Serv. 32, 7, 11–18, 1994. Burgess, A. W., Douglas, J. E., Burgess, A. G., Baker, T., Sauve, H., & Gariti, K. Hospital communication threats and intervention. J Psychosoc Nurs Ment Health Serv. 35, 8, 9–16, 1997.

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Carroll, V., & Goldsmith, J. One third of nurses are abused in the workplace. Reflections. 25, 3, 24–27, 1999. Centers for Disease Control and Prevention (CDC). Violence: Occupational hazards in hospitals. Available online at: http://www.cdc.gov/niosh/2002-101.html. Ciancone, A. C., Wilson, C., Collette, R., & Gerson, L. Sexual assault nurse examiner programs in the United States. Ann Emerg Med. 35, 4, 353–357, 2000. Drummond, D. J., Sparr, L. F., & Gordon, G. H. Hospital violence reduction among high-risk patients. JAMA. 261, 17, 2531–2534, 1989. Eckert, W. G., Bell, J. S., Stein, R. J., et al. Clinical forensic medicine. Am J Forensic Med Pathol. 7, 3, 182, 1986. Erickson, L., & Williams-Evans, S. A. Attitudes of emergency nurses regarding patient assaults. J Emerg Nurs. 26, 3, 210–215, 2000. Ernst, A., Green, E., Ferguson, M. T., Weiss, S. J., & Green, W. M. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. Ann Emerg Med. 36, 5, 432–437, 2000. Felton, J. S. Violence prevention at the health care site. Occup Med. 12, 4, 701–715, 1997. Garbacz-Bader, D. M. Forensic science program: A community effort. Am J Forensic Med Path. 19, 3, 242–245, 1997. Girardin, B. W., Faugno, D. K., Senski, P. C., Slaughter, L., & Whelan, M. Guidelines for giving effective testimony. In B. Girardin, D. K. Faugno, P. C. Senski, L. Slaughter, & M. Whelan (Eds.). Color Atlas of Sexual Assault. St. Louis, MO: Mosby. 1997. Groth, A., & Burgess, A. W. Sexual dysfunction during rape. New Engl J Med. 297, 14, 764–766, 1977. Hancock, P. Forensic nurse specialist: Forensic nursing. 2002. Available online at: www.ufcw141nurses.org/forensic %20ns.htm. Hanson, K. A., & Gidyez, C. A. Evaluation of a sexual assault prevention program. J Consul Clin Psycho. 61, 6, 1046–1052, 1993. Haywood, Y. C., & Scott, J. L. Domestic violence in the emergency department. Emergency Medicine Clinics of North America. 17, 3, 603–615, 1999. Hochmeister, M. N., Whelan, M., Gehrig, C., Binda, S., Berzlanovich, A., Rauch, E., & Dirnhofer, R. Effects of toluidine blue and destaining reagents used in sexual assault examinations on the ability to obtain DNA profiles from post-coital vaginal swabs. J Forensic Sci. 42, 2, 316–319, 1997. International Association of Forensic Nurses. Scope and Standards of Forensic Nursing Practice. Washington, DC: American Nurses Association Publishing. 1997. Irwin, K., Edlin, B., Wong, L., Faruque, S., McCoy, H., Word, C., Schilling, R., McCoy, C., Evans, P., & Holmberg, S. Urban rape survivors: Characteristics of human immunodeficiency virus and other sexually transmitted infections. Obstet and Gynecol. 85, 3, 330–336, 1995. Jenny, C., Hooton, T., Bowers, A., Copass, M., Krieger, J., Hillier, S., Kiviat, N., Corey, L., Stamm, W., & Holmes, K. Sexually transmitted diseases in victims of rape. New Engl J Med. 322, 11, 713–716, 1990.

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Koss, M., Gidyez, C., & Wisniewski, N. The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. J Consult Clin Psycho. 55, 162–170, 1987. Lanza, M. L., & Carifio, J. Blaming the victim. J Emerg Nurs. 17, 5, 299–309, 1991. Lanza, M. L. Environmental characteristics related to patient assault. Issues Ment Health Nurs. 15, 3, 319–335, 1994. Lauber, A. A., & Souma, M. L. Use of toluidine blue for documentation of traumatic intercourse. Obstet Gynecol. 60, 5, 644–648, 1982. LeBeau, M., Andollo, W., Hearn, W. L., Baselt, R., Cone, E., Finkle, B., Fraser, D., Jenkins, A., Mayer, J., Negrusz, A., Poklis, A., Walls, C., Lionel, R., Robertson, M., & Saady, J. Recommendations for toxicological investigations of drug-facilitated sexual assaults. J Forensic Sci. 44, 1, 227–230, 1999. Ledray, L. Evidence collection and care of the sexual assault survivor: The SANE-SART response, violence against women. 2001. Available online at: http://www.vaw.umn.edu /FinalDocuments/CommisionedDocs/ForensicEvidence .asp. Ledray, L. E., & Barry, L. Sexual assault: Clinical issues, SANE expert and factual testimony. J Emerg Nurs. 24, 3, 284–287, 1998. Ledray, L., & Summelink, K. Sexual assault: Clinical issues: Efficacy of SANE evidence collection, a Minnesota study. J Emerg Nurs. 23, 1, 75–77, 1997. Lenahan, L., Ernst, A., & Johnson, B. Colposcopy in evaluation of the adult sexual assault victim. Am J Emerg Med. 16, 2, 183–184, 1998. Levin, P. F., Hewitt, J. B., & Misner, S. T. Insights of nurses about assault in hospital-based emergency departments. Image J Nurs Sch. 30, 3, 249–254, 1998. Lion, J. R., Dubin, W. R., & Futrell, D. E. Creating a Secure Workplace: Effective Policies and Practices in Health Care. Chicago: American Hospital Publishing. 1996. Lipscomb, J. Violence in the workplace: A growing crisis among health care workers. In G. Fragala & W. Charney, Eds. The Epidemic of Health Care Worker Injury (pp. 163–165). Boca Raton, FL: CRC Press. 1999. Lurie, P., Miller, S., Hecht, F., Chesney, M., & Lo, B. Postexposure prophylaxis after nonoccupational HIV exposure. J Am Med Assoc. 280, 20, 1769–1773, 1998. Mahoney, B. S. The extent, nature, and response to victimization of emergency nurses in Pennsylvania. J Emerg Nurs. 29, 5, 21–26, 1991. McCauley, J., Gorman, R. L., & Guzinski, G. Toluidine blue in the detection of perineal lacerations in pediatric and adolescent sexual abuse victims. Pediatrics. 78, 6, 1039–1043, 1986. McCauley, J., Guzinski, G., Welch, R., Gorman, R., & Osmers, F. Toluidine blue in corroboration of rape in the adult victim. Am J Emerg Med. 5, 2, 105–108, 1987. McCracken, L. Forensic health care. 2002. Available online at: http://www.4n6links.com/forensichealthcare.htm. McCracken, L. The forensic nurse’s ABC’s of trauma care. 2002. Available online at: http://www.4n6links.com/abcs.htm.

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McCracken, L. Living forensics: A natural evolution of care. 2002. Available online at: http://www.4n6links.com/livingforensics.htm. McInerney, C. In a time of crisis proper crisis intervention saves lives. On Call. 11, 16–19, 1998. Merchant, R. Non-occupational HIV post-exposure prophylaxis: A new role for the emergency department. Ann Emerg Med. 36, 4, 2000. Mills, C. S., & Granoff, B. J. Date and acquaintance rape among a sample of college. Social Work. 37, 6, 504–509, 1992. Mittleman, R. E., Goldberg, H. S., & Waksman, D. M. Preserving evidence in the emergency department. Am J Nurs. 83, 1652, 1983. Murray, M. G., and Snyder, J. C. When staff are assaulted: A nursing consultation support service. J Psychosoc Nurs Ment Health Serv. 29, 7, 24–29, 1991. Nabb, D. Visitors’ violence: The serious effects of aggression on nurses and others. Nursing Standard. 14, 23, 36–38, 2000. Norvell, M. K., Benrubin, G. I., & Thompson, R. J. Investigation of micro-trauma after sexual intercourse. J Repro Med. 29, 269–271, 1984. Occupational Health and Safety Administration (OSHA). Guidelines for preventing workplace violence for health care and social service workers. Available online at: www.osha .gov/SLTC/workplaceviolence/guideline.html. Overman, S. Workplace violence: Threat from within. Occup Health and Safety. 54, 7, 24–27, 1995. Reilly, J. L. Curriculum proposal: Masters of science in forensic nursing. 2000. Available online at: http://www.newfoundations.com/CurrProjects/ForeN.html. Rhynard, J., Drebs, M., & Glover, J. Sexual assault in a dating relationship. J School Health. 67, 3, 89–93, 1997. Rickert, V. I., & Wiemann, C. M. Date rape among adolescents and young adults. J Pediatr Adoles Gynecol. 11, 167–175, 1998. Riggs, N., Houry, D., Long, G., Markovchick, V., & Feldhaus, K. Analysis of 1,076 cases of sexual assault. Annals of Emergency Medicine. 35, 4, 358–362, 2000. Ritchie, E. C. Reactions to rape: A military forensics psychiatrist’s perspective. Mil Med. 163, 505–509, 1998. Roper, J. M., & Anderson, N. L. The interactional dynamics of violence. Arch Psychiatr Nurs. 5, 4, 209–215, 1991.

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Rose, V. L. CDC releases the 1998 guidelines for the treatment of sexually transmitted diseases. Am Fam Physician. 57, 8, 2003–2008, 1998. Sackman, B. The role of the forensic nurse as an integral part of the criminal investigative team. Forensic Nurse. 2, 5, 2002. Schewe, P. A., & O’Donohue, W. Rape prevention with highrisk males: Short-term outcome of two interventions. Arch Sex Behav. 25, 5, 455–471, 1996. Simmons, M. M., & Cupp, M. J. Use and abuse of flunitrazepam. Ann Pharmacother. 32, 117–119, 1998. Simonowitz, J. A. Health care workers and workplace violence. Occup Med. 11, 2, 277–291, 1996. Sirotnak, S. P., & Sorotnak, A. P. Child abuse and forensic pediatric medicine fellowship curriculum statement. Child Maltreat. 5, 1, 58–63, 2000. Slaughter, L., & Brown, C. Colposcopy to establish physical findings in rape victims. Am J of Obstet Gyn. 166, 1, 83–86, 1992. Slaughter, L., Brown, C., Crowley, S., & Peck, R. The pattern of genital injury in female sexual assault victims. Am J Obstet Gyn. 176, 609–669, 1997. Smialek, J. E. Forensic medicine in the emergency department. Emerg Med Clin North Am. 1, 3, 1685, 1983. Smock, W. S., Ross, C. S., & Hamilton, F. N. Clinical forensic medicine: How ED physicians can help with the sleuthing. Emerg Legal Brief. 5, 1, 1–8, 1994. Sommargren, C. E. Violence as an occupational hazard in the acute care setting. AACN Clin Iss Crit Care Nurs. 5, 4, 516–522, 1994. Sullivan, M. K. Clinical forensic nursing: A higher standard of care. Forensic Nurse. 1, 1, 2002. Tintinalli, J., & Hoelzer, M. Clinical findings and legal resolution in sexual assault. Ann Emerg Med. 14, 5, 447–453, 1985. Yehuda, R. Managing anger and aggression in patients with posttraumatic stress disorder. J Clin Psychiatry. 60 (Suppl 15), 33–37, 1999. Yody, B. B., Schaub, C., Conway, J., Peters, S., Strauss, D., & Helsinger, S. Applied behavior management and acquired brain injury: Approaches and assessment. J Head Trauma Rehabil. 15, 4, 1041–1060, 2000.

Nurses’ Medico-Legal Skill Sets: 5 Forensic Observation, Documentation, Photography, and Evidence Collection CONTENTS 5.1 5.2 5.3 5.4 5.5

The Importance of Medico-Legal Skill Sets........................................................................................................... 81 Documentation in the Medical Record ................................................................................................................... 82 How Health Care Providers Can Improve Their Documentation Skills ................................................................ 85 Forensic Photography .............................................................................................................................................. 86 Evidence Collection................................................................................................................................................. 89 5.5.1 Documentation of Evidence ........................................................................................................................ 90 5.5.2 Contamination and Loss.............................................................................................................................. 91 5.5.3 Detection, Collection, and Preservation Techniques .................................................................................. 92 5.5.4 Site and Special Collection Considerations ................................................................................................ 92 5.5.5 Evidence Security ........................................................................................................................................ 93 5.5.6 Training Requirements for Trace Evidence Collection Personnel ............................................................. 93 5.5.7 Special Considerations in the Health Care Setting..................................................................................... 93 5.5.8 The Importance of Evidence Collection ..................................................................................................... 94 References ......................................................................................................................................................................... 95 Recommended Readings ................................................................................................................................................... 95

5.1 THE IMPORTANCE OF MEDICO-LEGAL SKILL SETS There are a number of specific skill sets that enable forensic nurses to perform their duties effectively according to proper forensic science protocol and appropriate nursing practice. Forensic nurses must be able to document their clinical findings in a cogent manner, whether it is through the use of photo-documentation of a patient’s injuries, or clear, descriptive narrations in the patient’s medical record following comprehensive interview and assessment processes. It is the integration of these skills with a nurse’s index of suspicion that creates a dynamic toolkit filled with clinical, psychosocial, and forensic interventions. Clinical nurse consultant Janet Barber, MSN, RN, says that in forensic nursing, the skills inherent to nursing practice are coupled with medico-legal principles that are built on these fundamentals: Characteristics and abilities of nurses, such as vigilance, nurturing, caring, and concern for a patient’s welfare, are everyday nursing behaviors that are engrained in individuals who become nurses; otherwise, they probably would not have become nurses in the first place. So, as a nurse,

you have this commitment to taking care of human beings and you go about it through standard nursing practice and through the application of standards that protect and defend a patient. I think that is where forensic nursing comes in; it is an application of an even higher set of standards and medico-legal processes that not only protect patients, but provide a defense for them in the event that they can’t speak or act for themselves.

The power of observation, which facilitates solid clinical assessment and documentation, is a key skill in a forensic nurse’s toolkit. Operating one’s forensic antenna and being swift on the uptake of information is critical, Barber notes, adding that it is the springboard for all other nursing practice. Barber says, historically, nurses have been dissuaded from reading too much into a patient’s situation, but forensic nurses have a special license to question and to investigate more fully. “Still there are some people who don’t think it’s a nurse’s business to investigate and to call certain scenarios into question,” Barber says: They think it’s the exclusive domain of the police officer, or it is someone else’s domain of practice. I believe most 81

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nurses are beginning to feel fairly sure-footed about their forensic or medico-legal responsibilities, and they are not going to allow themselves to be intimidated. I think that in general, all health care providers are realizing that they can be held legally accountable on obstruction of justice if they don’t pay more attention to injuries and ensure precise documentation of them. They are beginning to understand that this kind of attention to detail is no longer optional. I think that very recently, when nurses and physicians have been made responsible for reporting abuse and suspicious injuries and if they fail to report it is an obstruction of justice . . . that’s a pretty powerful motivator to observe injuries or signs of abuse, and to document, collect, and preserve medico-legal evidence.

Barber says that forensic nurses must use their keen skills of observation to corroborate the patient’s story and any injuries they might or might not be seeing during the patient interview and physical evidentiary examination. “Nurses must take in a lot of information at once, then begin to sort through the details,” Barber adds: Nurses must consider the patient’s behavior and their story; is what they are telling you believable? Does it make sense? Does it correspond to or contradict the patient’s injuries? Are they under the influence of drugs or alcohol? Once you can determine your patient’s behavior as normal or suspicious, you can begin to put into context your observations and begin to gather concrete physical information that concurs with what the patient is saying. Sometimes, the patient’s story doesn’t make sense; nurses have had patients tell them really bizarre things. For example, nurses in New Mexico have had people coming into the emergency department claiming they have been abducted and injured by aliens. Well, it sounds bizarre, of course, but yet when there are enough of these stories from otherwise “normal” people, they merit attention. The same goes for forensic cases. You record what you hear and what you see, and then you try to dissect it. I can’t emphasize enough the need to take down absolutely all of the information pertaining to a case, whether it makes sense at the time or not. Nurses must be absolutely obsessive-compulsive about detail when it comes to their documentation. Some of the smallest details that patients will tell you may not seem to be important at the time, but later on, you might ask yourself, “Did they tell me they were in the living room or in the kitchen when the incident happened? Who was there? Were there four people or one other person?” Forensic nurses pay attention to those details, they take it in, and they write it all down. These details may or may not ever be needed, or may never be important, but forensic nurses still document every single little detail. Sometimes your colleagues will say, “Wow, you sure wrote a lot about this case.” Well, it’s better to write a lot of detail and then find out you only need a little bit of that information, than wishing later on that you had remembered more of what the patient told you. If you don’t write it down, how can you possibly remember everything, and what if you missed something?

Forensic nursing is all about the business of being very detail-oriented.

5.2 DOCUMENTATION IN THE MEDICAL RECORD The patient interview is one of the most important steps in the documentation process says Kathleen Brown, RN, PhD, (2003) in “Evidence Collection and Preservation in a Health Care Setting.” She writes, “Whenever possible, health care personnel interview the victim, with or without a law enforcement person present. The interview guides the forensic examination by revealing what aspects of the body require the most attention. This process is similar to ED triage in which a member of the ED team asks questions to help focus the visit.” Health care personnel should record what the victim recalls in his or her own words as often as possible, Brown advises. “An ideal victim interview is a series of quotes, in quotation marks, of what the victim recalls about the crime committed. Statements made by the victim can be used in court. The role of the health care provider is not to analyze or place judgment on the words of the victim, but simply to record them . . . The victim’s description should not be sanitized or interpreted, just recorded with as many exact quotes as possible.” Brown adds that nurses might encounter patients who are unable to be interviewed. She states: Because health care concerns are always a priority, the interview may be delayed until the victim is medically stable; examination, evaluation, and treatment may proceed without interview. The interview may also be delayed if the victim is unconscious or semiconscious, and/or under the influence of alcohol or drugs. Evaluation, treatment, and testing should proceed in these situations without an interview, which can be conducted at a later time. When the victim cannot speak, careful documentation of all observations of the victim by health care personnel becomes crucial.

Mary Muscari, RN, NP, confirms, “Proper documentation is critical in forensic cases. Record direct quotes as often as possible, using quotation marks to indicate direct statements. Patients may use slang or vulgar terminology to describe what an assailant has done to them or to sanitize their own violent acts. Avoid paraphrasing the patient’s descriptions, using medical terminology, or correcting the patient’s grammar, since these detract from the credibility of the patient’s history.” She cautions nurses to avoid using potentially pejorative documentation. She writes, “The term ‘alleged’ may be used out of concern for making a wrongful accusation against someone. Conversely, writing the term ‘alleged’ in the record may imply reservations about the truthfulness of the

Forensic Nurses’ Medico-Legal Skill Sets

patient’s statements. Accurate, objective, and detailed documentation is required in forensic cases.” Forensic examiner Sharon Crowley, MN, RN, says forensic nurses must be “bullet-proof” when they are testifying in a court of law, and that means conscientious, complete documentation at all times: Documentation requires thoroughness, completeness, and objectivity. Bearing in mind that what you write in the medical record is subject to scrutiny by nursing and medical peers, and by juries in court can really change your whole perspective of documentation. As you document a patient’s injuries, collect and package the evidence, and take photographs, if you imagine the most severe scrutiny possible, it changes your whole approach and you dot every “i” and cross every “t” and you don’t leave anything to the imagination. Another compelling reason for careful and thorough documentation is knowing that if a case goes to court years later, you may forget the details if you don’t write them down. It’s like balancing a checkbook—you might let it go for a month or two but if you knew you were going to be audited tomorrow, you would make sure you made entries and balanced it every day. After a bad court experience or after testifying for the first time, it’s amazing how diligent you become in your documentation. All nurses may one day have to answer for their documentation in a court of law, and besides, good documentation is the right thing to do for the sake of the patient.

Clinical forensic nurse specialist Georgia Pasqualone, MSN, MSFS, RN, CEN, says she is troubled by the state of nursing documentation today. “There’s a problem with nursing documentation, and it’s poor nationally,” she says. “ED nurses in particular, often feel that they are too busy to document in a timely, consistent fashion, and that’s wrong but they do it anyway. When it comes to saving a hemorrhaging patient or writing in the medical record, the hemorrhaging patient wins out every time, and that’s the way it should be. But we need a better balance between the two.” Pasqualone believes a simple form of technology could facilitate busy nurses’ charting abilities: The ideal documentation process would involve nurses wearing a headset attached to a recording device, so that we were continually speaking into this little microphone. While we’re examining the patient, we can verbalize our findings, and it goes right into the tape recorder. Perhaps that would eliminate the fact we have to sit down and write something in the medical record. In reality, nurses are too busy to write, or sometimes you can’t find the chart. Or the chart is at the nurses’ station but you are in the patient’s room and standing between you and it is a very long walk down the hallway. Or you take the chart into the patient’s room but there’s no room to write, or you have dirty gloves on and don’t want to chart with them on, or whatever the scenario may be, there are many

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reasons why nurses don’t chart immediately after providing patient care. Like a lot of ED nurses, I am guilty of sometimes leaving all of my charting until the end of the shift . . . after a long, busy day, who remembers the small details of patient care? It’s a huge challenge and a significant problem that we must amend. We say that documentation should be complete, and we say that we should document after every assessment, every intervention, and every evaluation, but we don’t have time for that. That’s why I think that a great solution would be the headset and tape recorder. The tapes can be transcribed and placed in the medical record, and that way, nurses don’t miss anything at the time it is happening.

Another challenge to accurate documentation, Pasqualone notes, is the terminology that nurses use to document their observations in the medical record: I don’t teach people to name things, I teach them to describe what they see. You may not know what to call something forensically, but you certainly know how to describe it. So I tell nurses to record the dimensions of the injury, including measuring the width and length of the wound, describing its color and disposition. Nurses should never write that they think it’s a bruise that is two, three, or four days old, because it may not be a bruise, and we now know it’s tricky to tell how old a possible contusion might be. For example, one of my famous cases is of the elderly lady who was beaten up. Within an hour of presentation to the hospital, her bruises were deep purple and round; she had been on anti-coagulants, so her bruises looked a few days old when in fact they were only an hour or so old because her blood was so thin it turned colors rapidly. So you can never presume to know something definitively; you should only document what you see, what you smell, as well as the textures of things; use all five senses when you are documenting injuries, and don’t presume what these signs mean. Just write down what you observe.

Nancy Cabelus, MSN, RN, DABFN, concurs: We are trying to teach nurses not to write in the medical record “This is an entrance wound” or “This is an exit wound.” Instead, nurses should write that they observe two holes. Nurses must not box themselves in by what they write in a patient’s chart. They should be descriptive, but be careful not to call something by the wrong name. Cuts, lacerations, and blunt trauma often get confused and interchanged, so I tell other nurses to simply write down what you see; you don’t have to nail it down and say it’s definitely a bite mark. Support your descriptions with photographs whenever possible. In court, if it is established that a nurse used the wrong terminology, their credibility can be destroyed instantly. When I first came to law enforcement, I was told, “The more you write, the more trouble you get into. Keep it brief and to the point.”

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Well, you know what, when your murder case goes to court four years down the road, what are you going to remember? Probably very little. So you must write quite a bit, and do everything with an eye toward court. It may not seem to be forensically related at the time, but it certainly is.

“Details, details, details,” emphasizes Melissa Becker, RN, D-ABMDI, when asked about documentation in the medical record. “Start broad and narrow down your narrative,” she advises. “Your documentation should be thorough and detailed, providing a clear line from one end of the case to the other, which is easily followed and then easily understood whether it’s read tomorrow or two years from now.” Health care providers know that if they don’t document it, “it never happened.” Much has been done to better educate the health care community about the importance of documentation, especially when it comes to domestic violence. In a September 2001 research brief, Documenting Domestic Violence: How Health Care Providers Can Help Victims, published by the U.S. Department of Justice Office of Justice Programs, National Institute of Justice authors Nancy E. Isaac, ScD, senior research scientist with the Harvard Injury Control Research Center at the Harvard School of Public Health, and V. Pualani Enos, JD, assistant clinical professor at Northeastern University School of Law, Domestic Violence Institute, write: Many health care protocols and training programs now note the importance of such documentation. But only if medical documentation is accurate and comprehensive can it serve as objective, third-party evidence useful in legal proceedings. For a number of reasons, documentation is not as strong as it could be in providing evidence, so medical records are not used in legal proceedings to the extent they could be. In addition to being difficult to obtain, the records are often incomplete or inaccurate and the handwriting may be illegible. These flaws can make medical records more harmful than helpful. (Isaac & Enos, 1997)

There are still many health care providers who do not consider the consequences of incomplete or careless medico-legal documentation, particularly in abuse cases. A significant number of health care professionals have received scant information about how medical records can help domestic violence victims take legal action against their abusers. Isaac and Enos write, “They often are not aware that admissibility is affected by subtle differences in the way they record the injuries. By making some fairly simple changes in documentation, physicians and other health care professionals can dramatically increase the usefulness of the information they record and thereby help their patients obtain the legal remedies they seek.”

The victim’s attorney, or the victim acting on her own behalf as a pro se litigant, can submit medical documentation as evidence for obtaining a range of protective relief, such as a restraining order. Victims can also use medical documentation in less formal legal contexts to support their assertions of abuse. Persuasive, factual informa-

tion might qualify them for special status or exemptions in obtaining public housing, welfare, health and life insurance, victim compensation, and immigration relief related to domestic violence and in resolving landlord–tenant disputes. For formal legal proceedings, the documentation needs to be strong enough to be admissible in a court of law. Typically, the only third-party evidence available to victims of domestic violence is police reports, but these can vary in quality and completeness. Medical documentation can corroborate police data. It constitutes unbiased, factual information recorded shortly after the abuse occurs, when recall is easier. Medical records can contain a variety of information useful in legal proceedings. Photographs taken in the course of the examination record images of injuries that might fade by the time legal proceedings begin, and they capture the moment in a way that no verbal description can. Body maps can document the extent and location of injuries. The records might also hold information about the emotional impact of the abuse. However, the way the information is recorded can affect its admissibility. For instance, a statement about the injury in which the patient is clearly identified as the source of information is more likely to be accepted as evidence in legal proceedings. Even poor handwriting on written records can affect their admissibility. There are several reasons medical recordkeeping is not generally adequate. Health care providers are concerned about confidentiality and liability. They are concerned about recording information that might inadvertently harm the victim. Many are confused about whether, how, and why to record information about domestic violence, so in an effort to be “neutral,” some use language that could subvert the patient’s legal case and even support the abuser’s case. Some health care providers are afraid to testify in court. They might see the risks to the patient and themselves as possibly outweighing the benefits of documenting abuse. Even health care providers who are reluctant to testify can still submit medical evidence. Although the hearsay rule prohibits out-of-court statements, an exception permits testimony about diagnosis and treatment. In addition, some states also allow the diagnosis and treatment elements of a certified medical record to be entered into the evidentiary record without the testimony of a health care provider. Thus, in some instances, physicians and other health care providers can be spared the burden of appearing in court. The patient’s “excited utterances” or “spontaneous exclamations” about the incident are another exception

Forensic Nurses’ Medico-Legal Skill Sets

to the prohibition of hearsay. These are statements made by someone during or soon after an event, while in an agitated state of mind. They have exceptional credibility because of their proximity in time to the event and because they are not likely to be premeditated. Excited utterances are valuable because they allow the prosecution to proceed even if the victim is unwilling to testify. These statements need to be carefully documented. A patient’s report might be admissible if the record demonstrates that the patient made the statement while responding to the event stimulating the utterance (the act or acts of abuse). Noting the time between the event and the time the statements were made or describing the patient’s demeanor as she made the statement can help show she was responding to the stimulating event. Such a showing is necessary to establish that a statement is an excited utterance or spontaneous exclamation, and thus an exception to the hearsay rule. It appears that at present, many medical records are not sufficiently well documented to provide adequate legal evidence of domestic violence. A study of 184 visits for medical care in which an injury or other evidence of abuse was noted revealed these major shortcomings in the records: •

•

•

•

For the 93 instances of an injury, the records contained only one photograph. There was no mention in any records of photographs filed elsewhere (e.g., with the police). A body map documenting the injury was included in only three of the 93 instances. Drawings of the injuries appeared in eight of the 93 instances. Doctors’ and nurses’ handwriting was illegible in key portions of the records in one third of the patients’ visits in which abuse or injury was noted. All three criteria for considering a patient’s words an excited utterance were met in only 28 of the more than 800 statements evaluated (3.4 percent). Most frequently missing was a description of the patient’s demeanor, and often the patient was not clearly identified as the source of the information.

On the bright side, although photographs and body maps documenting injuries were rare, injuries were otherwise described in detail. In less than 1 percent of the visits were negative comments made about the patient’s appearance, manner, or motive for stating that abuse had occurred.

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5.3 HOW HEALTH CARE PROVIDERS CAN IMPROVE THEIR DOCUMENTATION SKILLS Medical records could be much more useful to domestic violence victims in legal proceedings if some minor changes were made in documentation. Clinicians can do the following: • •

•

•

•

•

•

•

•

Take photographs of injuries known or suspected to have resulted from domestic violence. Write legibly. Computerized medical records can also help overcome the common problem of illegible handwriting. Set off the patient’s own words in quotation marks or use such phrases as “patient states” or “patient reports” to indicate that the information recorded reflects the patient’s words. To write “patient was kicked in abdomen” obscures the identity of the speaker. Avoid such phrases as “patient claims” or “patient alleges,” which imply doubt about the patient’s reliability. If the clinician’s observations conflict with the patient’s statements, the clinician should record the reason for the difference. Describe the person who hurt the patient by using quotation marks to set off the statement. The clinician would write, for example: The patient stated, “My boyfriend kicked and punched me.” Avoid summarizing a patient’s report of abuse in conclusive terms. If such language as “patient is a battered woman,” “assault and battery,” or “rape” lacks sufficient accompanying factual information, it is inadmissible. Do not place the term “domestic violence” or abbreviations such as “DV” in the diagnosis section of the medical record. Such terms do not convey factual information and are not medical terminology. The court determines whether domestic violence has occurred. Describe the patient’s demeanor, indicating, for example, whether she is crying or shaking or seems angry, agitated, upset, calm, or happy. Even if the patient’s demeanor belies the evidence of abuse, the clinician’s observations of that demeanor should be recorded. Record the time of day the patient is examined and, if possible, indicate how much time has elapsed since the abuse occurred. For example, the clinician might write, “Patient states that early this morning her boyfriend hit her.”

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5.4 FORENSIC PHOTOGRAPHY As hand washing is to the prevention of disease transmission, so is forensic photography essential to the documentation of injuries in medico-legal cases. Both nursing interventions are critical to a patient’s welfare, and without them, health care providers run the risk of rejecting proper protocol. Photo documentation is one of the cornerstones of forensic nursing because it establishes a patient’s injuries and preserves a visual record of those injuries for permanent documentation. Should a civil or criminal lawsuit be filed in the future, this documentation can be used as key evidence to prove or disprove a plaintiff’s or a defendant’s claims. Experts say that proper photodocumentation is essential in those cases in which a victim of violence might present to the health care facility repeatedly, as the result of escalating abuse, even though the individual might attempt to minimize their injuries or fabricate stories to explain away their injuries. Photo documentation makes it more challenging for individuals to downplay or deny their abusive circumstances. Photography also provides a record of injuries that might have healed fully by the time a case goes to trial. In many cases, forensic photography can be a deciding factor in the minds of jurors. Brown (2003) writes, “Detection of injury is important to the investigation of a crime. Any injuries the victim sustained during the commission of a crime, regardless of whether they require medical intervention, must be noted and recorded. Injuries are photographed and described in the medical record, both in a narrative and drawn on a traumagram or body map.” Health care professionals should look for evidence of the various classifications of violence-related injuries, including blunt-force trauma, sharp-force injury, bite marks, abrasions, and lacerations. Although descriptions and drawings of injuries help investigations, it is photography that preserves the appearance of the victim in the immediate aftermath of the crime. Brown writes, “One photograph is worth a thousand words of narrative. And photographs of injury have a powerful effect on the law enforcement community.” Brown explains that because photographs preserve critical evidence, victims can use them in matters of restraint orders, divorce, and custody arrangements. Photography can also be used to assist rape and sexual assault victims in the investigative and judicial process. It also can be used to protect children who are victims of physical or sexual abuse. Photographs of the victim should be taken with cameras customarily used for forensic work, such as Polaroid instant, digital, or 35-mm cameras, before collection of trace evidence, Brown advises. These photographs document the appearance of the victim on arrival at the health care facility, and they must be taken before the victim is cleaned up or any part of his or her body is washed or

Forensic Nursing

dressed. The victim’s entire body should be carefully inspected for signs of injury, which then should be photographed. “Fresh injury can be difficult to detect, which is why the interview may be important to guide the search,” Brown writes. “If possible, take an initial overall picture of the victim as identification as well as documentation of the overall appearance before any medical intervention.” Brown adds that when injuries are fresh, light purple, and difficult to see in initial photographs, they can be rephotographed at a time deemed appropriate by law enforcement and health care personnel. She emphasizes, “But, if at all possible, photograph the injury before treatment ensues. Investigators want documentation of the appearance of injuries that appeared before medical intervention. If this is not possible, photograph immediately after intervention.” It is essential that all photographs be taken with a scale in place to indicate the dimensions of the injury. This scale, or forensic ruler, should not overlay any portion of the injury, but should be included in the photo and should identify the victim with a case or medical record number. A picture should be taken with and without the scale if possible, and all photographs should be taken at a 90degree angle reduce the probability of distortion. “Photographs will be accepted in court if the distance from the injury allows for accurate evaluation, the photograph is clear and in focus, and the scale is placed to allow for good visualization and measurement of the injury,” Brown adds. The forensic nurse should take an adequate number of photographs, being mindful that in a case of trauma or other medical emergency, taking perfectly composed photos might not be possible. Brown advises, “Quickly photograph what the victim looks like upon arrival and photograph any injuries as they are detected. Do not compromise the health care of the victim, but get those pictures!” If 35-mm film is used, it should be developed by law enforcement, Brown says, and if an instant camera is used, every photograph must be labeled with the victim’s name, the examiner’s name, the date, and the time the photo was taken. If digital photography is used, the disk should be given to law enforcement. Ledray (2001) writes, “Physical injuries are probably the best proof of force and need to be photographed, described on drawings, and documented in writing on the exam report. Ledray (1992a, 1992b) and Pasqualone (1996) say that photographs are not meant to take the place of thorough charting. They advise that health care providers take at least two sets of photographs; one set should be kept in the medical record, and the second set should be given to the police with other physical or trace evidence collected.

Forensic Nurses’ Medico-Legal Skill Sets

Ledray and Pasqualone instruct that when photographs are taken, health care providers should follow a systematic order, starting with the patient’s face, and working through the rest of the body from head to toe, and from front to back. They recommend that photo-documentation of injuries should be conducted using a 35mm camera with a standard 50-mm lens and 100 or 200 speed (ASA) color film. They explain that a disadvantage of 35-mm pictures is that they must be sent out for developing and often are not available to the police when they investigate, or to the prosecutor deciding to charge the case. Polaroid pictures have the advantage of being available to the police during their initial investigation, but they have the disadvantage of poorer quality, especially for close-ups. Some experts recommend taking both Polaroid pictures for use in the initial investigation and the charging decision-making process and 35-mm pictures that can be developed and used if the case goes to court. Although some examiners are hesitant to photograph a victim’s breasts and genitals, not properly documenting injuries with pictures could result in liability for failure to document, according to Pasqualone (1996). Health care providers can preserve a patient’s dignity by taking closeup pictures of the injury and by properly draping exposed areas. Although many nurses understand the importance of photographing the patient’s injuries, they are hesitant about breaking their particular state’s patient privacy laws. Pasqualone says: Recent conversations with emergency department colleagues have revealed that some health care providers are under the misconception that photo-documentation of patient injuries will breach confidentiality. On the contrary, photographs are considered as much a part of the medical record as is the written documentation. Neither gets separated from the record, and the information enclosed within does not get revealed outside the clinical setting until subpoenaed by the legal system.

Pasqualone recalls the case of an elderly woman who was brought into the ED from a nursing home with fever of unknown origin. When the patient was prepared for catheterization, the nurse observed massive swelling, contusions, and bruises in the patient’s perineal area. There were no other injuries on the woman’s body: Was this a result of anticoagulation therapy, or was this a situation of elder abuse? The nurse wanted to photo-document the injuries and report her observations to elder services, but was discouraged from doing either by the resident on call. The resident was under the impression that photographing the woman’s injuries, because they were on her genitalia, would not only be an invasive process, but would also breach her confidentiality.

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Pasqualone adds, “The truth of the matter is that by not photographing the woman’s injuries, health care personnel are committing an injustice to this patient. Photodocumentation preserves the injuries that will heal with time. If photo documentation does not become part of the written record, the patient will lose the impact for adjudication of this potentially abusive situation.” Pasqualone continues: As with all narrative notes, documentation of physical findings, clinical procedures, and diagrams of patient’s injuries, photographs are included in the medical record. If a patient is unable to give consent for photography, there is an implied consent, as treatable injuries are considered exigent evidence. In other words, evidence that will eventually vanish or be changed in appearance through healing or treatment is considered exigent and must be captured through photo documentation in order to complete the record.

Pasqualone advocates for all hospitals to have on hand a comprehensive photo-documentation protocol prior to the arrival of any forensic category of patient: Ideally, photo-documentation should be included in the blanket permission to treat. As with any treatment generated in the ED, the patient always has the option of refusing or declining. If a patient does not want photographs taken of their injuries, they still have that right to refuse. There will come a day when hospitals and health care providers will be sued for not photographing the injuries due to trauma and/or violent crime. This will be an act of neglect on the part of the clinicians. The police have been photo-documenting for many years. Their photographs lend only to the investigative process, though. Health care providers, especially those in the ED, are in the ideal situation for visualizing injuries, recognizing them as evidence, and preserving them for any future litigation. In effect, they are advocating for their patients. The knowledgeable public is becoming more and more aware of the fact that photographs provide a tremendous impact in the courtroom. It is the proactive hospital and the educated health care provider with a vision toward the future that not only treats the patient, but also protects his or her civil rights.

Cabelus raises an issue on the minds of many new forensic nurses. “It’s unclear for many nurses whether or not they have the authority to take pictures,” she says. “They ask, ‘What if the patient says no?’ ‘Do I need to get consent?’” Mary Sullivan chimes in, “Nurses have a lot of trouble in their minds sorting out what’s confidential and what’s not, according to HIPAA regulations. Nurses just want to take care of their patients, so they just want to bypass all of those issues. I think we definitely need rules and regulations that allow us to get those pictures when we need to.”

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Cabelus says many nurses also raise the question of chain-of-custody issues with the film: Nurses ask constantly, “Where does the film go if you don’t have a lab in your hospital?” I gave a lecture last year and addressed some of these issues. I told attendees to keep a camera and a stock of 35-mm film in their medication room in the ED, and that when it is ready to be processed, someone is going to have to hand carry that film to a photo-processing place and stand by for the one hour while it is being developed. So they wrote down all of this. About six months later I taught the same class and I asked who had a photography policy. This nurse raises her hand and says her hospital has a new photography policy as well as a separate consent form for photos, that they keep a camera and film handy, and that a nurse takes the film to the local Piggly Wiggly and she stands by and waits for it to be developed. I said, “That’s wonderful. When did you start doing this?” And she replied, “One of our nurses took your class six months ago and that’s the information she came back with.” I was delighted to see somebody had been listening and then they utilized the plan. If we can get this to spread like a rash, it would be great!

Photography can have a significant impact on cases relating to interpersonal violence, and the importance of photo documentation in a forensic case cannot be understated, prosecutors emphasize. “From the moment an arrest is made, the clock is ticking,” says San Diego Assistant City Attorney Gael Strack of the San Diego County Domestic Violence Unit. “In our profession, speed is essential because each suspect must be arraigned within 72 hours of the time of arrest. Evidence in the form of photographs must be collected right away.” Instant photo documentation has helped San Diego achieve a 90 percent conviction rate and Los Angeles a 95 percent conviction rate when dealing with domestic violence cases. Strack says one of the reasons for San Diego’s successful prosecution track record and a 75 percent drop in domestic violence homicides since 1985 is the philosophy that cases must be prosecuted with or without the victim’s participation. “If we have enough evidence to go forward, we do. This means we need to document the injuries and the statements. We rely heavily on the Polaroid instant photographs taken by police officers at the scene for our cases.” She says the San Diego Police Department (SDPD) documents about 12,000 domestic violence cases annually, with more than 4,000 victims displaying visible injuries. The SDPD uses Polaroid Macro 5 and Spectra cameras equipped with the law enforcement close-up kit. “The benefit of having instant photos is that pictures don’t recant, pictures don’t minimize, pictures don’t change their story,” Strack says. “Pictures do paint a very painful picture. And that’s what juries need to see to be convinced that a crime has occurred.”

Strack says that proper photo documentation of injuries is essential because it is crucial in establishing the chain of evidence required to prosecute; photo documentation helps prosecutors secure early guilty pleas from offenders, reducing court costs and caseloads; and cases can be successfully prosecuted without the victim’s testimony when proper documentation is provided. An instant photo imaging system is beneficial because instant photos are tamper resistant, unlike conventional 35-mm and digital images. Instant camera users can see immediately that the right image was captured, minimizing the number of photos taken per case. Instant photos provide evidence before an officer leaves the scene, unlike 35-mm photos or digital images (which can be improperly exposed or misplaced). Instant photos also become part of the case file immediately, particularly important for fast arraignments. Injuries should be thoroughly documented in the following steps: • • • • • •

•

•

• •

•

•

When possible, take photographs before medical treatment is given. Photograph from different angles, full-body and close-up. Include the patient’s face in at least one photograph. Hold up a coin, ruler, or other object to illustrate the size of an injury. Take at least two pictures of every major trauma area. One-on-one or close-up photos of the victim’s injuries, including fresh bruising, abrasions and lacerations, should be taken. A second close-up or midrange set of photos that includes the victim’s face for identification purposes, should be taken. Check for indications of past abuse, including scars, or cluster or faded bruising, which could be evidence of abuse over an extended period. Check for defensive injuries, especially on the forearms. The scene of the violence also should be thoroughly documented, including taking photos of overturned or broken furniture, smashed pictures, mirrors, glasses or dishware, or phones ripped out of the wall. These kinds of photos show the severity of the violence. Document any evidence of drug or alcohol abuse or any evidence of violence against children, including images showing them crying, scared, upset, or injured. Photograph the batterer, if present at the scene, or obtain a copy of his or her photo if he or she has fled.

Forensic Nurses’ Medico-Legal Skill Sets

•

•

•

Label each photograph with patient’s name, birth date, date and time photo was taken, and the signature of the person taking the photograph. Place in a sealed envelope and mark as confidential. Place on the left side of chart in the section marked “Do not release.” Document in notes that photographs were taken.

“Whatever will effectively document what happened at the scene, we want recorded,” Strack says. “Police will photograph the victim’s injuries. If there are children present we ask the officers to take a picture of the children. If anything has been damaged, for instance, if he has put his fist through the wall, we want a picture of that. If a weapon has been used, they take a picture of that. Officers also photograph the perpetrator to capture any injuries he’s sustained.” Because domestic violence includes the dynamics of love and fear, some victims recant their statements within several days after the incident. The use of detailed police reports, statements, and clear photographic evidence allow prosecutors to proceed with the case without pressuring the victim to cooperate. “The more photographs, the better,” Strack says. “When we go back into court six months later to try to prove that a crime occurred, the pictures tell the story of what happened long after the physical wounds have healed.” Pictures truly can be worth a thousand words. Pasqualone (1996) writes, “There is absolutely no way that a nurse can accurately document the extent of 53 stab wounds on a victim's body with the written word. There is no way to accurately document the bridging of a laceration, blood-flow patterns showing directionality or the extent of an abrasion ring around a gunshot wound.” She emphasizes that photography cannot and should not replace documentation in the medical record, but “it certainly should be the No. 1 form of supplemental documentation . . . photographic documentation in the search for the truth continues to exist after the wounds are healed, and will persist for the attorneys and judges to utilize in their pursuit of guilt or innocence.” Nurses must understand, Pasqualone says, that they can be held responsible for not documenting trauma, injuries, and signs of abuse, exposing their health care institution to potential legal liability. “By failing to properly photograph evidence related to injuries, health care providers who help restore a crime victim’s physical wellbeing may ruin that patient’s changes of redress through the courts, or more importantly, jeopardize that victim’s future safety,” she adds. Photographs of evidence on clothing, such as bullet holes, debris, stains, and tears, can corroborate the story told by the victim or the perpetrator, and Pasqualone says, “Each of these elements tells a story that

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could be destroyed if rolled up in a ball and thrown into the garbage or washed down a sink.” Many hospitals are including a separate patient photography release form as part of the facility’s paperwork on admission, with instructions to explain to patients the purpose of photography and the reasons why these photographs might be important to the patient if legal action is taken.

5.5 EVIDENCE COLLECTION In 1987, the first individual was convicted of sexual assault with the assistance of deoxyribonucleic acid (DNA) evidence, and in 1991, the Minnesota Bureau of Criminal Apprehension (BCA) Laboratory became the first state crime lab to identify a suspect on the basis of DNA alone. Ledray and Netzel (1997) reported that as a result of this valuable investigative resource, an otherwise unidentified rapist was found and convicted. The acknowledgment of DNA as a valuable investigative tool, as well as the fact that numerous rapists are repeat offenders, led to the development of the FBI’s Combined DNA Index System (CODIS). DNA issues are described in greater detail in chapter 14. Ledray and Netzel (1997) say that DNA evidence should be obtained by collecting any available blood evidence that could be from the assailant on the skin or clothing of the victim. If the survivor reports she scratched the assailant, fingernail scrapings should be collected in hopes of collecting the assailant’s blood. DNA can also be obtained by swabbing the involved orifices with a standard-size cotton-tip swab for sperm and seminal fluid. Additionally, when the forensic examiner completes the evidentiary exam, blood evidence should be collected from the survivor for DNA analysis to distinguish her DNA from that of the assailant. Regarding seminal fluid evidence, Tucker, Ledray, and Stehle-Werner (1990) caution that the absence of positive sperm or seminal fluid findings does not prove there was no recent sexual intercourse. Studies have indicated that 34 percent or more of rapists are sexually dysfunctional (Groth & Burgess, 1977), and as many as 40 percent wear condoms (Larkin & Paolinetti, 1998). Seminal fluid evidence is usually analyzed for sperm, motile or nonmotile, and for prostatic specific acid phosphatase. The enzyme acid phosphatase is present in large quantities in seminal fluid and minimal concentrations in vaginal fluids, so if a high level of acid phosphatase is collected in a sexual assault victim, this would ndicate that recent sexual contact occurred. When Tucker et al. (1990) examined the results of 1,007 rape survivors, sperm was found in 1 percent of the 369 cases involving oral rape. All of the positive oral specimens were collected within three hours of the rape. Of the 210 cases with rectal involvement, only 2 percent

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were positive for sperm. These exams were all completed within four hours of the rape. In the 111 skin specimens collected, 19 percent were positive. All but two of the positive specimens were collected within four hours of the rape. Of the 919 vaginal specimens, 37 percent were positive. Of these, 263 were examined within five hours and 317 were examined within 12 hours of the rape. Only seven of the positive specimens were collected more than 20 hours after the rape. In the same study, the acid phosphatase results were better by approximately a factor of 10. Of the oral specimens, 11 percent were positive; 12 percent of the rectal specimens were positive; 43 percent of the skin specimens were positive; and positive responses were obtained in 62 percent of the cases involving vaginal assault. Roach and Vladutiu (1993) compared prostatic acid phosphatase (PAP) to prostatic specific antigen (PSA) and found, in a sample of 212 women who had consensual sex within four days, that more positive results were obtained with PAP analysis. Although both were positive 59 percent of the time, PAP was positive 84 percent of the time and PSA was positive 60 percent of the time. PAP was negative only 2 percent of the time when PSA was positive, and PSA was negative 25 percent of the time when PAP was positive. Forensic nurses must be well versed in the correct procedures and techniques for the identification, documentation, collection, and preservation of trace evidence from both the individual presenting in the clinical environment, and from the crime scene, whether it is within or separate from the health care institution. An understanding of trace evidence collection is predicated on Locard’s Exchange Principle, which states that whenever two objects come into contact, a transfer of material occurs (Locard, 1930). Trace evidence that is transferred can be used to associate objects, individuals, or locations. Kathleen Brown, RN, PhD, explains that the goal of any forensic examination within a health care setting is to identify and collect evidence that has transferred from the offender to the victim. Brown (2003) writes, “When a crime involves close contact between the victim and the offender, in such crimes as assault, sexual assault, and physical abuse, evidence transfers to the crime scene and the victim. While law enforcement personnel preserve and collect evidence from the crime scene, health care personnel can preserve and collect it from victims.” She explains that evidence must be collected systematically and comprehensively “without inducing psychological or physical harm to the victim,” and adds, “The system for evidence collection and preservation involves a careful search of the entire body, requiring careful identification and retention of all evidence from the victim.” Brown continues, “Health care personnel can play an important role in assisting in the investigation of crime, while providing health care to the victim. However, the

Forensic Nursing

forensic work of collecting and preserving evidence should never compromise the safety of a patient, the first priority. And members of the health care community should be able to handle forensic evidence without compromising health care.” The integrity and significance of trace material as associative evidence relies on proper detection, collection, and preservation, and an understanding of the transfer and persistence of trace evidence will assist the examiner in interpreting the significance of the analytical results. The U.S. Department of Justice and the FBI, through its Trace Evidence Recovery Guidelines, presents cogent instructions for health care providers when it comes to the collection of pertinent forensic evidence.

5.5.1 DOCUMENTATION

OF

EVIDENCE

When a case is initiated, a specific file for that case must be created to contain the case documentation for the length of time required by the prevailing laws and nonconflicting agency policy. Documentation of questioned and known trace evidence collection must include permanent notes about the following: • • • • •

The date (and time, when appropriate) of the collection The name of the person collecting the evidence A descriptive listing of items collected A unique identifier for each item collected, such as an item number and case number The location of each item (documented by notes, sketches, measurements, photographs, or a combination of these)

The chain of custody for each item must be initiated at collection and maintained until final disposition. Recommended procedures for documenting and labeling physical evidence are outlined in ASTM Standard E 145992, Standard Guide for Physical Evidence Labeling and Related Documentation (9.2), and Standard E 1492-92, Standard Practice for Receiving, Documenting, Storing, and Retrieving Evidence in a Forensic Science Laboratory. Ledray (1999) says that many experts caution against the forensic examiner collecting detailed investigative information, and suggest that the SANE should ask only for information necessary to collect the proper medical evidence, deal with the immediate physical and psychological needs of the survivor, and collect and interpret the physical and laboratory findings. The SANE should remember that he or she is conducting a medical forensic interview that centers on the survivor and not other assault details or investigative information, such as the height or weight of the assailant. The defense attorney might use details reported by the nurse, which differ from the police report, to show discrepancies in the survivor’s story. The only necessary

Forensic Nurses’ Medico-Legal Skill Sets

documentation is that needed to guide the exam and treat the survivor (Ledray, 1999; Slaughter, 1992). Basic documentation should include the following:

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tions. General principles and practices to avoid evidence contamination and loss include the following: •

• • • • • • • • •

• • • • • • • •

Site and time of assault Nature of physical contacts Race and number of assailants Relationship to assailants Weapons and restraints used Actual and attempted penetration of which orifice by penis, objects, or fingers Ejaculation, if known, and where Use of condom Activities of the victim that might have destroyed evidence, such as bathing, douching, or bowel movement Consensual sex within the last 72 hours and with whom Use of tampon Change of clothes Contraceptive use Current pregnancy Allergies Victim’s general appearance and response during exam Physical injuries

Ledray adds that it is important to remember that in addition to the assault exam report, the entire chart is a part of the legal record and can be submitted as evidence if the case goes to court. All statements, procedures, and actions must be accurately, completely, and legibly recorded (Blair & Warner, 1992). It is important to accurately and completely document the emotional state of the survivor and quote important statements made by the survivor, such as threats made by the assailant (Ledray, 1999; Sheridan, 1993). When appropriate, qualifying statements such as, “patient states . . .” or “patient reports . . .” should be used. If the exam findings match the history given by the survivor, the examiner should also document “there is congruence between the victim’s story and her injuries” (Sheridan, 1993). Sheridan also states that the term “alleged sexual assault” should never be used in documentation of a sexual assault, as the term has negative connotations and might be interpreted by judges and juries as indicating the victim exaggerated or lied.

5.5.2 CONTAMINATION

AND

LOSS

When collecting or examining items, care must be taken to prevent contamination and loss of trace materials. Unless circumstances dictate otherwise, the trace evidence should be collected and preserved prior to other examina-

•

•

•

•

•

•

•

•

Contact between items and personnel before the appropriate trace evidence has been secured should be restricted. Appropriate protective apparel, such as laboratory coats and disposable gloves, must be worn to prevent contamination from the examiner’s clothing. The apparel must be changed as necessary to avoid contamination or transfer between evidentiary items, locations, and personnel. Items being collected for trace evidence examination must be handled as little as possible to minimize loss of the trace evidence and to limit exposure of the items to contaminants. Collect, package, and seal items individually in appropriate packaging. Keep items in a secure, sealed package until the item is processed in a controlled environment. Equipment and work surfaces used during collection and examination must be cleaned in an appropriate manner before processing begins and as often as necessary during processing to prevent contamination. Adhesive-lift materials (used for collection, storage, or both) must be maintained in a manner to avoid contamination. Caution should be used to prevent tape edges from contacting any unclean surfaces. Evidence examination areas should have adequate lighting, easily cleaned surfaces, and a physical environment designed to restrict excessive air currents, static electricity, and general foot traffic. The examination of questioned and known items for trace evidence must be conducted separately in different locations, at different times, or both, to prevent contamination. It is recommended that questioned items with the most probative value be examined first. Any contact, condition, or situation that could cause contamination or otherwise compromise the trace evidence examination must be documented and communicated between the laboratory analyst or analysts and the submitter.

Ledray (1999) says that although it is suggested that specimens be refrigerated for long-term storage to prevent deterioration, it is essential that the evidence be kept in an area at less than 75 degrees Fahrenheit and the blood evidence not be frozen, meaning that storage in an airconditioned room is sufficient for the short term.

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5.5.3 DETECTION, COLLECTION, AND PRESERVATION TECHNIQUES When selecting detection, collection, and preservation methods and the processing sequence, consider the circumstances of the case, ambient conditions, the discriminatory power of the different techniques, and the need to preserve or collect other types of evidence. Record the techniques used for detection, collection, and preservation of the evidentiary items and the location from which they are removed. Methods used for detecting trace evidence include but are not limited to general visual searches; visual searches assisted by different types of illumination, such as oblique lighting and alternate light sources (ultraviolet, laser, high intensity); and visual searches assisted by magnification. Trace evidence recovery or collection techniques used should be the most direct and least intrusive techniques practical. Collection techniques include picking, lifting, scraping, vacuum sweeping, combing, and clipping: •

•

•

•

Picking: Trace evidence can be separated from an item by using clean forceps or other implements. The collected samples should be immediately protected against loss or contamination. Lifting: An adhesive-bearing substrate such as tape is repeatedly and firmly patted or rolled over the item, causing loosely adhering trace evidence to stick to the tape. Do not overload the tape. The collected lifts are typically placed on a transparent backing (e.g., clear plastic sheeting, glass slides, and clear plastic or glass petri dishes). This protects against contamination and permits samples to be easily viewed and removed for further comparison. Scraping: A clean spatula or similar tool is used to dislodge trace evidence from an item onto a collection surface such as clean paper. The collected debris is immediately packaged in a manner to avoid sample loss. This technique is most often conducted within the laboratory in a controlled environment that reduces the risk of contamination or loss of the trace evidence. Vacuum sweeping: A vacuum cleaner equipped with a filter trap is used to recover trace evidence from an item or area. The filter and its contents should be immediately packaged to avoid sample loss. The appropriate vacuum parts, filter, and trap must be changed and rigorously cleaned between each vacuuming to avoid contamination. Consider using this method subsequent to other collection techniques as it is indiscriminate and might result in the collection of a large amount of extraneous material.

•

•

Combing: A clean comb or brush is used to recover trace evidence from the hair of an individual. The combing device and collected debris from the hair should be packaged together. Clipping: Trace evidence can be recovered from fingernails by nail clipping, scraping, or both. Fingernails can be clipped with clean scissors or clippers and packaged in clean paper. Fingernails can be scraped with a clean implement to collect debris from underneath them. Package the collected debris and the scraping device as one unit, typically in clean paper. Commonly, fingernails from the right and left hands are packaged separately. This does not preclude the collection of each or any nail separately from all others, such as a nail with obvious damage.

Appropriate preservation and packaging of trace evidence and items to be examined for trace evidence will vary. Appropriate packaging must prevent loss or contamination of the trace evidence. All evidence packages must be properly sealed to prevent tampering and eliminate loss or contamination of the trace evidence through open edges. Small or loose trace evidence must be secured in clean, unused primary containers such as paper packets or petri dishes. The primary container should then be appropriately secured in an envelope or paper bag. Large items, such as whole garments, should be sealed individually in clean, unused packaging. Clothing and other items that are wet must be air dried as soon as possible, without exposure to heat or sunlight, in a secured area in a manner that will prevent loss or contamination of trace evidence. An arrangement to collect any trace evidence that might fall from the item during drying should be used. Small or manageable items at a crime scene that bear visible, firmly attached trace evidence should be documented, packaged intact, and transported to the laboratory for examination. Items at a crime scene that bear visible but easily lost trace evidence, or items that are impractical to transport should be documented and the trace evidence collected by an appropriate technique.

5.5.4 SITE AND SPECIAL COLLECTION CONSIDERATIONS Individuals responsible for the detection and collection of trace evidence should be aware of the applicable laws governing search warrants, searches, and seizures within their jurisdiction. They should be aware that various types of evidence will be present during the processing of a crime scene or the examination of items submitted to the laboratory. Some types of evidence other than trace evidence might be more significant to a particular case and

Forensic Nurses’ Medico-Legal Skill Sets

therefore should be given higher priority. Representative known samples of an item, sufficient to represent all variations that could be present within that item, should be collected for comparison with the questioned trace evidence. The areas from which these samples are collected must be documented. Patterned marks or impressions might be encountered and might require additional documentation and collection procedures such as 1:1 scale photography. Enhancement techniques such as oblique lighting or powder dusting and preservation techniques such as adhesive lifting or casting should be considered. The possibility of physically matching a fractured, broken, torn, or cut portion of an object to its source should always be considered. The entire questioned item and possible source item should be collected, protecting the edges from further deformation. When the possibility of a physical match exists, one should not overlook the necessity of maintaining all items separately to prevent contamination.

5.5.5 EVIDENCE SECURITY Trace evidence must remain in secure, controlled-access areas, protected from loss, damage, or contamination. It must have a documented and continuous chain of custody from the time of collection until the time the evidence is admitted into court or the case has been disposed and the evidence is no longer needed. The security and integrity of evidence is the responsibility of all persons who might identify, collect, package, store, transport, or examine evidentiary items. Ledray (1993) says that maintaining a proper chain of evidence is as important as collecting the proper evidence. She writes, “Without this complete documentation, with signatures, of chain-of-custody from the individual who collected the evidence to the courtroom, the evidence will be inadmissible.” Ledray adds that it is not necessary, nor is it appropriate, for the police officer to be in the exam room when the evidence is collected to maintain a proper chain of evidence. The police officer can leave the area and the forensic nurse can call him or her when the exam is completed to return and pick up the evidence. Both signatures on the chain-of-evidence document are all that is necessary. When the police cannot immediately return, the SANE can place the evidence in a locked storage area, preferably a refrigerator with limited access, and when the police do return, any available nurse can sign.

5.5.6 TRAINING REQUIREMENTS FOR TRACE EVIDENCE COLLECTION PERSONNEL The responsibility of trace evidence collection can be assigned to personnel of varying occupations and levels of expertise, such as crime scene technicians, law enforce-

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ment personnel, and medical personnel. These personnel must be trained in trace evidence detection, collection, and preservation techniques. Training should include but not be limited to the recordkeeping protocol of the agency; crime scene search techniques; rules of evidence handling; safety concerns of evidence handling and detection techniques; legal aspects of search warrants, seizures, and evidence recovery; chain-of-custody requirements; storage of physical evidence; the detection, collection, and preservation methods used for trace evidence; contamination prevention; and the significance of trace evidence analysis results.

5.5.7 SPECIAL CONSIDERATIONS CARE SETTING

IN THE

HEALTH

Kathleen Brown advocates strict adherence to best practices for evidence collection and preservation in the health care setting. One of the more frequently encountered pieces of physical evidence in the ER or the OR is a bullet, and great care should be taken to handle it as little as possible. She explains that metal forceps can damage the exterior of a bullet, making it more difficult for ballistics experts to match the bullet to a particular firearm. She says that the teeth of the forceps should be covered with a plastic shield if they are used to recover a bullet; once removed, the bullet should be wrapped in gauze and placed in an envelope. Documentation of the removal of a bullet should include what it is, the patient from whom it was removed, and who removed it, as well as date and time. The bullet should be turned over to the police. Brown (2003) adds that health care providers should bear the following in mind when observing and documenting violence-related wounds: •

•

Health care personnel should not take it on themselves to determine whether a wound is an entrance or an exit gunshot wound, unless the victim is able to describe entry versus exit. Brown writes, “If health care personnel determine entrance versus exit incorrectly, a discrepancy will appear when the expert is consulted. Conflicting reports can mislead investigators.” Health care personnel should observe wounds for gunshot powder residue, which will be deposited on the patient’s skin and clothing if the victim was shot at a close range (less than three feet). Photographs of the wound with surrounding gunpowder should be taken before removal of the gunpowder. Following photodocumentation, the powder residue should be removed by scraping some of it onto a piece of paper and placing the paper into an envelope. Brown writes, “In cases of suicide, gunshot powder will be found on the victim’s hands. If

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•

•

suicide is suspected, the victim’s hands should be covered in paper bags until an expert examines them.” Health care providers should never use stab wounds for treatment access, such as for the insertion of tubes or catheters; new insertion sites should be chosen. The victim’s stab wounds should be photographed before medical intervention whenever possible. Clothing worn by a victim during the commission of a crime can hold important clues, including bullet holes, stab holes, rips, and tears, and should be collected by a gloved examiner and placed into clean paper bags. Each item of clothing should be placed in a separate paper bag to prevent transfer of evidence. Each bag should be sealed with evidence tape, labeled with the item of clothing, the victim’s name, the collector’s name, and the time and date of collection. If clothing worn during the crime must be cut for removal, cutting should avoid altering any evidence, such as rips, tears, cuts, and holes that resulted from the assault. Brown writes: If clothing worn during the crime has been removed before the patient arrived at the health care setting, it should be retrieved and placed in paper bags by law enforcement personnel, who will deliver it to the police crime laboratory for analysis. In medical emergencies the clothing is often forgotten and discarded. Investigators of crime would appreciate health care personnel tossing the clothing aside, at the very least, rather than losing it to the trash in the ED.

Brown explains that there are three kinds of forensic evidence that can be collected in the health care setting: evidence identifying the perpetrator, evidence indicating if force was involved, and evidence placing the victim at the crime scene. Brown writes, “Evidence should be collected whenever possible before it is disturbed by medical intervention or cleaning. ‘Cleaning up’ the victim removes valuable evidence and should occur after evidence collection, if at all possible.” Brown adds, “For forensic examiners, the skin is the most important organ of the body.” She advocates meticulous examination of the victim’s skin for any transfer of evidence from the perpetrator, including saliva, semen, or other body fluids. Forensic examiners should collect any random hair, fibers, or debris, and place it into a druggist’s paper and then into a clean envelope. Each envelope must be labeled with the victim’s name, the examiner’s name, and the date and time of collection, as well as its contents and from where on the victim’s body the evidence came. Brown says health care providers

should maintain custody of the evidence at all times until it is turned over to law enforcement.

5.5.8 THE IMPORTANCE

OF

EVIDENCE COLLECTION

Ledray, Faugno, and Speck (2001) write, “It has been only in recent years that our health care facilities have begun to recognize their responsibility to have trained staff available to provide this specialized service for victims of sexual assault. Treating injuries alone is not sufficient.” A New York hospital learned the importance of chain of custody issues the hard way. According to Ledray et al.: In 2000, Coney Island Hospital was fined $46,000 by state regulators after a rape victim came to the medical facility and a sexual assault evidentiary examination was not accurately performed. She was made to wait three hours before being examined and then potentially significant evidence, including her underwear and vaginal swabs, was lost. The Department of Health investigation also found that the hospital did not provide her with medication to prevent pregnancy and they failed to provide complete care. The authorities believed that had correct evidence collection and chain-of-custody occurred, the evidence may have been useful to secure a conviction against the serial sex offender charged with her rape. As a result New York passed the Sexual Assault Reform Act requiring New York State medical facilities to develop specialized sexual assault examiner evidence collection programs in 2001.

In 2000, New York Times writer C. J. Chivers described it as a “game of chance” that exists in most U.S. hospitals when facilities don’t have the proper forensic protocols or specially trained medical staff to respond to sexual assault cases. Chivers compared two sex crime cases to illustrate the differences competency can make in the judicial process. In one case, a woman’s attackers were convicted of aggravated sexual abuse and are serving long prison sentences. In another case, the one described by Ledray et al., the assailant, a serial sex offender, secured a lenient plea bargain for attempted assault and was eligible for a parole hearing. Chivers wrote, “The drastically different outcomes of these similar cases were the result of what prosecutors, physicians and victims’ advocates describe as a game of chance inside emergency rooms at New York City Hospitals. The first woman received a thorough examination that documented evidence of the attack. The second woman did not.” Chivers pointed out that years after health care facilities were afforded a forensic protocol, the level of competence in administering evidentiary exams varied widely. “This uneven quality of care, experts say, can mean an uneven quality of evidence with which to prosecute some of society’s most malevolent criminals.” In the first sexual assault case, the victim was met by a physician sexual assault examiner, who performed the

Forensic Nurses’ Medico-Legal Skill Sets

evidentiary exam, including use of a Wood’s Lamp to identify minute amounts of DNA that can be collected, and to document vaginal injury through use of a colposcope. Using the colposcope, the examiner was able to locate and photograph genital abrasions that were consistent with sexual assault and that could support a prosecutor’s charge. Chivers reported that a according to a law enforcement authority, one of the defendants—who had denied all charges—was presented with the contents of the medical file; when confronted with the evidence of injury, he pleaded guilty to the maximum charge and accepted a 15year prison sentence. Ledray et al. report that one study conducted in the Midwest showed that prosecutors introduced 48 percent more evidence in cases in which victims were treated in examiner-based programs.

REFERENCES American Society for Testing and Materials (ASTM). ASTM E 1492-92: Standard Practice for Receiving, Documenting, Storing, and Retrieving Evidence in a Forensic Science Laboratory. West Conshohocken, PA: ASTM. Blair, T., & Warner, C. Sexual assault. Top Emerg Med. 14, 4, 58–77, 1992. Brown, K. Evidence collection and preservation in a health care setting. Available at: www.nursingspectrum.com. 2003. Chivers, C. J. In sex crimes, evidence depends on game of chance in hospitals. New York Times. August 6, 2000. Groth, A., & Burgess, A. W. Sexual dysfunction during rape. New Engl J Med. 297, 764–766, 1977. Isaac, N. E., & Enos, P. Medical records as legal evidence of domestic violence (pp. 1–76). Washington, DC: U.S. Department of Justice. 1997. Larkin, H., & Paolinetti, L. Pattern of anal/rectal injury in sexual assault victims who complain of rectal penetration. IAFN Sixth Annual Scientific Assembly. Pittsburgh, PA. October 1–5, 1998. Ledray, L. E. The sexual assault examination: Overview and lessons learned in one program. J Emerg Nurs. 18, 3, 223–232, 1992a. Ledray, L. E. The sexual assault nurse clinician: Minneapolis’ 15 years experience. J Emerg Nurs. 18, 3, 217–221, 1992b. Ledray, L. E. Sexual assault nurse clinician: An emerging area of nursing expertise. In L. C. Andrist, Ed., Clinical Issues in Perinatal and Women's Health Nursing. Philadelphia: J.B. Lippincott. 1993. Ledray, L. E. Sexual assault: Clinical issues: Date rape drug alert. J Emerg Nurs. 17, 1, 1–2, 1999. Ledray, L. E. Evidence collection and care of the sexual assault survivor: The SANE-SART response. Violence Against Women Online Resources. August 2001. Ledray, L. E., Faugno, D., & Speck, P. Sexual assault: Clinical issues. SANE: Advocate, forensic technician, nurse? J Emerg Nurs. 27, 1, 91–93, 2001. Ledray, L. E., & Netzel, L. Forensic nursing: DNA evidence collection. J Emerg Nurs. 23, 2, 182–186, 1997.

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Locard, E. The analysis of dust traces. Part I. Am J Police Science. 1, 276–298, 1930. Pasqualone, G. A. Forensic RNs as photographers: Documentation in the ED. J Psychoso Nurs. 34, 10, 1996. Roach, B. A., & Vladutiu, A. O. Letter to the editor: Prostatic specific antigen and prostatic acid phosphatase measured by radioimmunoassay in vaginal washings from cases of suspected sexual assault. Clinica Chimica Acta. 216, 199–201, 1993. Sheridan, D. J. The role of the battered woman specialist. J Psychoso Nurs. 31, 11, 1993. Slaughter, L., & Brown, C. R. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol. Jan;166, 83–86 1992. Tucker, S., Ledray, L. E., & Stehle-Werner, J. Sexual assault evidence collection. Wisconsin Med J. 89, 407–411, 1990. U.S. Department of Justice, Federal Bureau of Investigations. Trace Evidence Recovery Guidelines. Forensic Science Communications. 1, 3, 1999.

RECOMMENDED READINGS De Forest, P. R., Gaensslen, R. E., & Lee, H. C. Forensic Science: An Introduction to Criminalistics. New York: McGrawHill. 1983. Federal Bureau of Investigation. Handbook of Forensic Science. Washington, DC: Government Printing Office. 1994. Fisher, B. A. J., Svensson, A., & Wendel, O. Techniques of Crime Scene Investigation (Fourth Edition). New York: Elsevier. 1987. Moreau, D. M. Physical Evidence in Sexual Assault Cases. New York: Elsevier. 1987. Moreau, D. M., & Allen, S. P. Forensic Techniques Used to Search Persons for Physical Evidence in Crimes of Violence. Washington, DC: Federal Bureau of Investigation, Forensic Science Training Unit. 1989. Nelson, D. F., & Revell, B. C. Backward fragmentation from breaking glass. J Forensic Sci Soc. 7, 58–61, 1967. Olshaker, J., Jackson, M., & Smock, W. Forensic Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins. 2001. Pasqualone, G. A. Capturing more than the moment. Forensic Nurse. 2002. Pasqualone, G.A. The role of photography in the emergency room. Polaroid Advocate Instant Evidence e-Newsletter. 2003. Pearson, E. F., May, R. W., & Dabbs, M. D. G. Glass and paint fragments found in men’s outer clothing: Report of a survey. J Forensic Sci. 16, 283–300, 1971. Pounds, C. A. The recovery of fibres from the surface of clothing for forensic examinations. J Forensic Sci Soc. 17, 132–140, 1972. Pounds, C. A., & Smalldon, K. W. The transfer of fibres between clothing materials during simulated contacts and their persistence during wear. Part I: Fibre transference. J Forensic Sci Soc. 15, 17–27, 1975.

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Pounds, C. A., & Smalldon, K. W. The transfer of fibres between clothing materials during simulated contacts and their persistence during wear. Part II: Fibre persistence. J Forensic Sci Soc. 15, 29–37, 1975. Pounds, C. A., & Smalldon, K. W. The transfer of fibres between clothing materials during simulated contacts and their persistence during wear. Part III: A preliminary investigation of the mechanisms involved. J Forensic Sci Soc. 15, 197–207, 1975. Pounds, C. A., & Smalldon, K. W. The distribution of glass fragments in front of a broken window and the transfer of fragments to individuals standing nearby. J Forensic Sci Soc. 18, 197–303, 1978. Quill, J. L. The transfer theory of hairs applied to the normal work day. In Proceedings of the International Symposium on Forensic Hair Comparisons (pp. 141–142). Washington, DC: Federal Bureau of Investigation. 1985. Robertson, J., Ed. The forensic examination of fibres—Protocols and approaches: An overview. In Forensic Examination of Fibres. New York: Ellis Horwood. 41–98, 1992.

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Robertson, J., Kidd, C. B. M., & Parkinson, H. M. P. The persistence of textile fibres transferred during simulated contacts. J Forensic Sci Soc. 22, 353–360, 1982. Robertson, J., & Lloyd, A. K. Observations on redistribution of textile fibres. J Forensic Sci Soc. 24, 3–7, 1984. Saferstein, R., Ed. Forensic Science Handbook (Vol. I & II). Englewood Cliffs, NJ: Prentice Hall. 1988. Saferstein, R. Criminalistics: An Introduction to Forensic Science (Seventh Edition). Englewood Cliffs, NJ: Prentice Hall. 2001. Scott, H. G. The persistence of fibres transferred during contact of automobile carpets and clothing fabrics. Canadian Soc Forensic Sci J. 18, 185–199, 1985. Simon, A. Hair evidence on laundered items. Crime Laboratory Digest. 13, 3, 78–81, 1986. Spitz, W. U. Spitz and Fisher’s Medicolegal Investigation of Death (Third Edition). Springfield, IL: Charles C Thomas. 1993.

6 Sexual Assault CONTENTS 6.1 6.2 6.3

6.4

6.5 6.6

6.7 6.8

6.9

Sexual Violence Is a Global Problem ..................................................................................................................... 99 Sexual Assault Hits Closer to Home: The Domestic Problem............................................................................. 100 6.2.1 The Challenge of Underreporting ............................................................................................................. 101 Sexual Violence: Definitions, Prevalence, and Characteristics............................................................................. 101 6.3.1 Definitions of Sexual Assault .................................................................................................................... 101 6.3.2 Types and Characteristics of Sexual Violence .......................................................................................... 102 6.3.3 Typology of Rape ...................................................................................................................................... 102 6.3.4 Deconstructing a Rape Case ..................................................................................................................... 103 Health-Related Consequences of Sexual Violence ............................................................................................... 105 6.4.1 Physical Impacts ........................................................................................................................................ 105 6.4.2 Psychological Impacts ............................................................................................................................... 105 6.4.2.1 Rape Trauma Syndrome......................................................................................................... 105 6.4.2.2 PTSD ...................................................................................................................................... 106 6.4.3 Harmful Behaviors Triggered by Sexual Assault ..................................................................................... 107 Victims’ Utilization of Medical Services.............................................................................................................. 108 The Health Care Response to Sexual Violence .................................................................................................... 109 6.6.1 Experiences in the ER ............................................................................................................................... 109 6.6.2 Physicians as Part of the Equation............................................................................................................ 110 6.6.3 Emergency Physicians Address the Issue of Sexual Violence ................................................................. 110 6.6.4 Nurses as Part of the Equation.................................................................................................................. 113 6.6.5 A Nurse’s Issue: Emergency Contraception ............................................................................................. 113 6.6.6 Development of the SANE/SART Program.............................................................................................. 119 6.6.6.1 Demonstrating the Need for the SANE Program.................................................................. 121 6.6.6.2 A Model SANE Program....................................................................................................... 122 6.6.6.3 A Model SART Program ....................................................................................................... 123 6.6.6.4 Obstacles to the SANE/SART Program ................................................................................ 124 6.6.6.5 The Challenge to Nurse Examiners ....................................................................................... 125 6.6.6.6 In Defense of SANE and SART Programs ........................................................................... 126 6.6.7 The Evidentiary Examination.................................................................................................................... 131 6.6.8 Training of Health Care Providers ............................................................................................................ 132 The Cost of Sexual Assault ................................................................................................................................... 132 Quality-of-Care Issues........................................................................................................................................... 133 6.8.1 Mandatory Reporting................................................................................................................................. 133 6.8.2 Addressing the Issues of Quality of Care................................................................................................. 134 6.8.3 Evidence of SANE/SART Efficacy........................................................................................................... 135 6.8.4 Health Care Provision for Victims of Sexual Violence ............................................................................ 138 6.8.5 General Considerations for Health Care Delivery.................................................................................... 140 6.8.5.1 Ethical Issues.......................................................................................................................... 141 6.8.5.2 Timing of Health Care Delivery ............................................................................................ 141 6.8.5.3 The Setting of the Examination ............................................................................................. 141 The Medico-Legal Examination Environment...................................................................................................... 141 6.9.1 Facilities for Sexual Assault Victims ........................................................................................................ 141 6.9.2 Equipment and Supplies............................................................................................................................ 142 6.9.2.1 General Medical Supplies ...................................................................................................... 142 6.9.2.2 Forensic Supplies ................................................................................................................... 142 97

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6.9.2.3 Treatment Supplies................................................................................................................. 142 6.9.2.4 Linen Supplies........................................................................................................................ 142 6.9.2.5 Sundry Supplies...................................................................................................................... 143 6.9.2.6 Documentation Supplies......................................................................................................... 143 6.9.3 Special Considerations .............................................................................................................................. 143 6.9.3.1 Sexual Assault Kits ................................................................................................................ 143 6.9.4 The Initial Assessment .............................................................................................................................. 147 6.9.4.1 Conduct of Health Care Providers......................................................................................... 147 6.9.4.2 Demeanor of the Health Care Provider ................................................................................. 148 6.9.4.3 Obtaining Consent.................................................................................................................. 148 6.9.4.4 Taking a History ..................................................................................................................... 148 6.9.4.5 Obtaining a General Medical History.................................................................................... 148 6.9.4.6 Obtaining an Account of the Assault..................................................................................... 149 6.9.4.7 The Physical Examination...................................................................................................... 149 6.9.4.8 The “Top-to-Toe” Physical Examination ............................................................................... 150 6.9.4.9 The Genito-Anal Examination ............................................................................................... 151 6.9.4.10 Recording and Classifying Injuries........................................................................................ 153 6.9.4.11 Injury Description................................................................................................................... 153 6.9.4.12 Classification of Wounds........................................................................................................ 153 6.9.4.13 Wound Categories .................................................................................................................. 153 6.9.4.14 Genito-Anal Injuries Related to Penetration ......................................................................... 154 6.9.4.15 Injury Patterns and Their Interpretation ................................................................................ 155 6.9.5 Follow-Up on Health Care Services Among Victims............................................................................... 155 6.10 Genital Injuries in Sexual Assault Victims ........................................................................................................... 156 6.10.1 Genital Trauma .......................................................................................................................................... 157 6.10.2 Patterns of Genital Injuries in Sexual Assault Victims and Issues of Consent........................................ 158 6.10.3 Postmortem Genital Examinations............................................................................................................ 164 6.10.4 Up Close and Clinical With Sharon Crowley........................................................................................... 165 6.10.5 Genital Injury: An Issue in the Courtroom............................................................................................... 168 6.10.6 Use of Colposcopy in Sexual Assault Examinations................................................................................ 169 6.10.7 Sexual Assault Examination, Reporting, and the Legal Outcome of Cases ............................................ 169 6.11 Drug-Facilitated Sexual Assault ............................................................................................................................ 173 6.12 A National Protocol for Handling Sexual Assault Cases ..................................................................................... 177 6.12.1 Overarching Issues .................................................................................................................................... 178 6.12.1.1 Coordinated Approach............................................................................................................ 178 6.12.1.2 Victim-Centered Care............................................................................................................. 178 6.12.1.3 Informed Consent ................................................................................................................... 179 6.12.1.4 Confidentiality ........................................................................................................................ 179 6.12.1.5 Reporting to Law Enforcement.............................................................................................. 179 6.12.1.6 Payment for the Examination Under the VAWA ................................................................... 180 6.12.2 Operational Issues...................................................................................................................................... 180 6.12.2.1 Sexual Assault Forensic Examiners ....................................................................................... 180 6.12.2.2 Facilities.................................................................................................................................. 180 6.12.2.3 Equipment and Supplies......................................................................................................... 181 6.12.2.4 Sexual Assault Evidence Collection Kit ................................................................................ 181 6.12.2.5 Timing Considerations for Collecting Evidence ................................................................... 181 6.12.2.6 Evidence Integrity .................................................................................................................. 182 6.12.2.7 The Examination Process....................................................................................................... 182 6.12.2.8 Triage and Intake.................................................................................................................... 182 6.12.2.9 Documentation by Health Care Personnel............................................................................. 183 6.12.2.10 The Medical Forensic History ............................................................................................... 183 6.12.2.11 Photography............................................................................................................................ 183 6.12.2.12 Exam and Evidence Collection Procedures........................................................................... 184 6.12.2.13 Drug-Facilitated Sexual Assault............................................................................................. 184 6.12.2.14 STI Evaluation and Care........................................................................................................ 184

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6.12.2.15 Pregnancy Risk Evaluation and Care..................................................................................... 185 6.12.2.16 Discharge and Follow-Up ...................................................................................................... 185 6.12.2.17 Examiner Court Appearances................................................................................................. 185 References ....................................................................................................................................................................... 185 Recommended Readings ................................................................................................................................................. 190

Sexual assault is an expansive clinical specialty that overlaps into many other aspects of forensic nursing practice. For the purposes of introduction, this chapter discusses broad principles of sexual violence, and subsequent sections take a closer look at abuse of and violence toward vulnerable populations such as children, the elderly, and the disabled.

6.1 SEXUAL VIOLENCE IS A GLOBAL PROBLEM Sexual violence is ubiquitous; it occurs in every culture, at all levels of society, and in every country of the world. Data indicate that, in some parts of the world at least, one woman in every five has suffered an attempted or completed rape by an intimate partner during her lifetime (World Health Organization, 2003). Additionally, as many as one third of women worldwide describe their first sexual experience as being forced, not consensual. Although the vast majority of victims are women, men and children of both sexes also experience sexual violence. Sexual violence is a global problem that must be reckoned with by health care providers and members of law enforcement and the legal community. The World Health Organization (WHO) maintains that at least one woman in five has been physically or sexually abused by a man at some time in her life. Women are more at risk from those they know—husbands, fathers, neighbors, or colleagues—than they are from strangers (WHO, 2003). Globally, gender violence includes sexual harassment, sexual coercion, assault, and rape as well as battering, trafficking, forced prostitution, dowry-related violence, female genital mutilation, sex-selective abortion, and female infanticide. The Declaration on the Elimination of Violence Against Women, adopted by the United Nations General Assembly in 1993, defines violence against women as any act of gender-based violence that results or is likely to result in physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation of liberty, whether occurring in public or private life. WHO defines sexual violence as “Any sexual act, attempt to obtain a sexual act, unwanted sexual comments, or advances, or acts to traffic a person’s sexuality, using coercion, threats of harm or physical force, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.”

In a 2003 multicountry study undertaken by WHO, women who were able to give information anonymously were almost twice as likely to report having experienced sexual abuse before the age of 15 as women who were interviewed face to face. When women have more than one opportunity to do so, they are more likely to disclose violence. Violence is nearly always underreported by women because they believe it is “normal,” they fear that making it public will cause them harm or shame; or they are not ready to talk about it, so levels of violence reported are often minimum levels of actual violence. Often violence does not come to light until it is specifically looked for. In 48 surveys on intimate partner violence around the world that asked direct questions such as, “Has a current or former partner ever hit you with his fist or with something else that could hurt you?” 10 percent to 69 percent of women reported being hit or physically assaulted by a current or former husband or boyfriend and 3 percent to 52 percent reported such violence in the year preceding the study. Coercive sex in intimate partnerships is more common if women are also physically assaulted. Studies in Mexico and the United States estimate that 40 percent to 52 percent of women experiencing physical violence from an intimate partner have also been sexually abused by that partner. Intimate partner violence can also affect men, but there is a significant gender gap between women and men in terms of quantity of violence and severity of injury, with women much more heavily affected. The dynamics of violence between men and women also differ with studies reporting men seeking to exert dominance, power, or control over women or circumscribe them to particular gender roles, whereas many women who physically abuse husbands have often been abused themselves. Studies of child sexual abuse from 20 countries, including 10 national representative surveys, showed rates of childhood sexual abuse of 7 percent to 36 percent for girls and 3 percent to 29 percent for boys, with most studies reporting rates 1.5 to 3 times higher against girls (WHO, 2003). Sexual violence has a significant negative impact on the health of the population. The potential reproductive and sexual health consequences are numerous, including unwanted pregnancy, sexually transmitted infections (STIs), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and increased risk for adoption of risky sexual or health behaviors. The mental health consequences of sexual violence can be just as serious and enduring. Victims of child sexual abuse, for example, are more likely to experience depression, substance abuse,

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posttraumatic stress disorder (PTSD), and suicide in later life than their nonabused counterparts. Worldwide child sexual abuse is a major cause of PTSD, accounting for an estimated 33 percent of cases in females and 21 percent of cases in males (WHO, 2003). Even if they fail to disclose the event itself, persons who have experienced sexual violence often seek medical assistance. Leserman (1998) and Campbell (2002) studied the relationships between intimate partner violence, health status, and female use of health care, and found that abused women consume more medical care than nonabused women. Survivors who choose to report the assault to the police are often taken to a health care facility for examination and treatment, particularly if the assailant was a stranger. Irrespective of the circumstances, health care providers who come into contact with victims of sexual violence are pivotal to the recognition of, and response to, individual cases of sexual assault. Victims of sexual assault require comprehensive, gender-sensitive health services to cope with the physical and mental health consequences of their experience and to aid their recovery from an extremely distressing and traumatic event. The types of services that are needed include emergency contraception, STI testing or prophylaxis, treatment of injuries, and psychosocial counseling. In addition to providing immediate health care, the health care and medical communities can act as an important referral point for other services that the victim might need, such as social welfare and legal aid. Swart (2000) says that health care providers are also prepared to collect and document the evidence necessary for corroborating the circumstances of the assault, and for identifying the perpetrator and the health consequences of the event. Such evidence is often crucial to the prosecution of cases of sexual violence. In most countries, however, there is a gap between the health care and medico-legal needs of victims of sexual violence and the existing level of services provided in such cases (Acosta, 2002; Chaudhry, 1995; Cohen, de Vos, & Newberger, 1997). For instance, in many countries, victims of sexual violence are not examined by a specially trained medico-legal examiner or health care provider. In some cases, victims are subjected to multiple examinations in surroundings that do not meet minimum health standards. Furthermore, until now, published protocols or guidelines for health care professionals on the medical management of persons who have experienced sexual violence have not been widely available.

6.2 SEXUAL ASSAULT HITS CLOSER TO HOME: THE DOMESTIC PROBLEM Sexual assault, including rape and attempted rape, is an equally distressing problem in the United States. Estimates of the prevalence of rape and other forms of sexual assault

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vary from study to study, but even the most narrowly focused estimates provide a sense of the breadth of the problem. In 2000, almost 147,000 persons over age 12, male and female, were victims of rape or attempted rape (U.S. Department of Justice, 2001). In 2002, there were 247,730 victims of rape, attempted rape, or sexual assault. Of these approximately 248,000 victims, about 87,000 were victims of completed rape, 70,000 were victims of attempted rape, and 91,000 were victims of sexual assault (U.S. Department of Justice, 2002). Because of the methodology of the NCVS of the U.S. Department of Justice Bureau of Justice Statistics, these figures do not include victims 12 or younger. Although there are no reliable annual surveys of sexual assaults on children, the Justice Department has estimated that one of six victims are under age 12. According to the Rape, Abuse & Incest National Network (RAINN), every two minutes, somewhere in America, someone is sexually assaulted; this calculation is based on the 2002 NCVS of the Bureau of Justice Statistics of the U.S. Department of Justice. One out of every six American women have been the victims of an attempted or completed rape in their lifetime (14.8 percent completed rape, 2.8 percent attempted rape). A total of 17.7 million women have been victims of these crimes, according to the Prevalence, Incidence, and Consequences of Violence Against Women Survey by the National Institute of Justice and Centers for Disease Control and Prevention in 1998. In 2002, seven out of every eight rape victims were female (NCVS, 2002). About 3 percent of American men—a total of 2.78 million men—have experienced an attempted or completed rape in their lifetime. In 2002, one in every eight rape victims were male (NCVS, 2002). About 44 percent of rape victims are under age 18. Three out of every 20 victims (15 percent) are under the age of 12 (U.S. Department of Justice, 1997). Seven percent of girls in grades five to eight and 12 percent of girls in grades nine through 12 said they had been sexually abused. Three percent of boys in grades five through eight and 5 percent of boys in grades nine through 12 said they had been sexually abused. Ninety-three percent of juvenile sexual assault victims knew their attacker; 34.2 percent were family members and 58.7 percent were acquaintances. Only 7 percent of the perpetrators were strangers to the victim (U.S. Department of Justice, 2000). One of the most startling aspects of sex crimes is how many go unreported. The most common reasons given by victims for not reporting these crimes are the belief that it is a private or personal matter and that they fear reprisal from the assailant. In 2001, only 39 percent of rapes and sexual assaults were reported to law enforcement officials, or about one in every three (NCVS, 2002). Of sexually abused children in grades five through 12, 48 percent of boys and 29 percent of girls had told no one about the abuse, according to the Commonwealth Fund Survey of the Health of Adolescent Girls (1998).

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Most rapists aren’t masked men in the night, according to statistics. Approximately 66 percent of rape victims know their assailants (NCVS, 2000). Approximately 48 percent of victims are raped by a friend or acquaintance; 30 percent by a stranger; 16 percent by an intimate; 2 percent by another relative; and in 4 percent of cases the relationship is unknown (NCVS, 2000). Sixty-one percent of sexual assaults are not reported to the police. Those rapists, of course, never serve a day in prison (NCVS, 1999). If the rape is reported to police, there is a 50.8 percent chance that an arrest will be made. If an arrest is made, there is an 80 percent chance of prosecution. If there is a prosecution, there is a 58 percent chance of a felony conviction. If there is a felony conviction, there is a 69 percent chance the convict will spend time in jail. So, even in the 39 percent of attacks that are reported to police, there is only a 16.3 percent chance the rapist will end up in prison. Factoring in unreported rapes, about 6 percent of rapists, or one out of 16, will ever spend a day in jail; 15 out of 16 will walk free.

6.2.1 THE CHALLENGE

OF

UNDERREPORTING

The WHO (2003) states that there is significant underreporting of sexual violence; therefore, published statistics are therefore unlikely to provide an accurate picture of the true scale of the problem. This also creates difficulties when attempting to compare studies. The reasons for nonreporting are complex and multifaceted but typically include fear of retribution or ridicule, and a lack of confidence in investigators, police, and health care professionals. Men are even less likely than women to report being a victim of sexual violence and for this reason information about the extent of sexual violence against males is especially limited. It is also very difficult to establish true incidence rates, and even prevalence estimates, of child sexual abuse, again largely because of underreporting. Child sexual abuse is rarely reported when the abuse occurs, and in many cases is never reported. Most prevalence data come from asking adults about their past experiences. Moreover, many countries lack a reliable reporting system for child sexual abuse. The situation is compounded by the fact that definitions of child sexual abuse vary among countries, making comparisons difficult. What data are available from studies conducted in different parts of the world suggest that between 7 percent and 36 percent of girls, and between 3 percent and 29 percent of boys have suffered from child sexual abuse. The majority of studies concluded that sexual violence against girls is anywhere from 1.5 to 3 times more widespread than that against boys. Of the reported cases of child sexual abuse, only 10 percent to 15 percent involve boys, a finding that highlights the discrepancy between reporting and occurrence of sexual violence in boys. The trafficking of women and children for prostitution is becoming one of the fastest growing areas of international criminal activity.

According to official estimates, somewhere between 1 million and 2 million women and children are trafficked each year worldwide for forced labor, domestic servitude, or sexual exploitation. Generally speaking, women of lower economic status are more susceptible to sexual slavery, trafficking, and sexual harassment (WHO, 2003).

6.3 SEXUAL VIOLENCE: DEFINITIONS, PREVALENCE, AND CHARACTERISTICS 6.3.1 DEFINITIONS

OF

SEXUAL ASSAULT

A challenge for the health care, law enforcement, and legal communities has been to get on the same page when it comes to how certain terms are defined. The terms rape, sexual assault, sexual abuse, and sexual violence are generally considered synonymous and are often used interchangeably. However, these terms might have very different meanings (and implications) in varying situations and locations. More significantly, legal definitions of specific types of sexual violence might differ from the medical and social definitions, and furthermore, can vary among countries and even within countries. It is important, therefore, that health care professionals are aware of the legal definitions of sexual violence within their own jurisdiction (WHO, 2003). The word rape has been used to define forced or attempted sexual intercourse with a male or female, by an offender that can be of the same sex or a different sex from the victim. Sexual assault is usually defined to encompass rape, attempted rape, forced oral and anal sex, penetration with objects, touching of intimate parts, and other types of threats or coercion in which unwanted sexual contact is attempted or occurs between the victim and offender. Studies have attempted to group rape and attempted rape as one of several types of sexual assault. However, the NCVS defines sexual assault as a “wide range of victimizations separate from rape or attempted rape.” For legal purposes, rape and sexual assault are defined by each state, and they differ in terms of what specific acts are included or excluded, what the age of consent for sexual intercourse is, and other details that affect the medico-legal process of prosecution, penalties, and sentences. According to a 2003 report, Guidelines for MedicoLegal Care for Victims of Sexual Violence, commissioned by the WHO, sexual violence is defined as, “Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women’s sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home and work” According to this definition, a wide range of behaviors, from rape at gunpoint to sexual coercion under a threat of dismissal (i.e., with false agreement), would be classified as an act of sexual violence. False agreement to sexual

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activity can be obtained in a variety of ways; for instance, through threats of physical violence, threats of withholding benefits, psychological pressure, or blackmail. Agreement in such circumstances does not amount to freely given consent. The same is true in cases of sexual acts involving individuals who are unable to give consent; that is to say, individuals who are not capable of understanding the significance of the act or of indicating their consent or refusal (e.g., those who are incapacitated due to the effects of alcohol or drugs, or those with a mental disability). Such acts would also be described as nonconsensual (Saltzman, 1999).

6.3.2 TYPES AND CHARACTERISTICS VIOLENCE

OF

SEXUAL

Sexual violence can take many forms and take place under very different circumstances. A person can be sexually violated by one individual or several people (gang rapes), or the incident might be a planned or a surprise attack. Although sexual violence occurs most commonly in the victim’s or perpetrator’s home, it also takes place in many other settings. The perpetrator of a sexual assault might be a date, an acquaintance, a friend, a family member, an intimate partner or former intimate partner, or a complete stranger; more often than not, however, it is someone known to the victim. There is no stereotypical perpetrator; sexually violent men come from all backgrounds: rich and poor, academic and uneducated, religious and nonreligious. Perpetrators could be persons in positions of authority who are respected and trusted, and thus less likely to be suspected of sexual violence.

6.3.3 TYPOLOGY

OF

RAPE

There are many good texts that discuss the typology of rape; for purposes of this work, the various types of sexual offenders are summarized briefly. In “Rape Violence,” authors A. Nicholas Groth, Ann Wolbert Burgess, Carol R. Hartman, and Lynda Lytle Holstrom observe that, “The most basic observation one can make regarding rapists is that not all such offenders are alike. They do not do the very same thing in the very same way or for the very same reason.” In all cases of rape, however, the researchers found three ever-present components: anger, power, and sexuality. They explain, “The hierarchy and interrelationships among these three factors, together with the relative intensity with which each is experienced and the variety of ways in which each is expressed, may vary from one offense to another.” They add that there is sufficient clustering so that distinguishable patterns of rape become evident: the anger rape, in which sexuality becomes a hostile act; the power rape, in which sexuality becomes an expres-

sion of conquest; and the sadistic rape, in which anger and control become eroticized. Groth et al. write, “In every act of rape, then, both aggression and sexuality are involved; but it is clear, however, that sexuality becomes the means of expressing other, nonsexual needs and feelings which operate in the offender and motivate his assault. Rather than being primarily an expression of sexual desire, rape is, in fact, the use of sexuality to express issues of power and anger.” They say that rape is a sexual act having more to do with status, aggression, control, and dominance than with sexual pleasure and satisfaction. “It is sexual behavior in the service of nonsexual needs and, in this sense, rape is clearly a distortion of human sexuality.” In cases of anger rape, the researchers explain, “sexuality becomes a means of expressing and discharging feelings of intense anger, rage, contempt, hatred, and frustration; the assault is characterized by excessive brutality.” They say that the assault is one of “explosive physical violence to all parts of the victim’s body. This type of offender approaches his victim by striking and beating her. He tears her clothes, knocks her to the ground, uses abusive and profane language, rapes her, and frequently makes her perform or submit to additional degrading acts.” The offender in this kind of rape appears to be more impulsive than premeditated, and a precipitating stressor—such as a significant woman in the offender’s life—might set him off. “The conflict he experiences in this relationship reaches a crisis level and then becomes activated by some upsetting altercation or frustrating interaction with this individual. The resulting fury is released and discharged in a sexual assault against a victim who may be, but more frequently is not, the actual person towards whom the offender harbors such feelings.” The researchers add, “Sex becomes a weapon, and rape is the means by which he can use this weapon to hurt and degrade his victim. His intent is to hurt his victim, and his assault is brutal and violent. His motive is revenge and punishment. In extreme cases, this may result in homicide.” In cases of power rape, Groth et al. say, the offender typically uses only whatever force is necessary to overpower his victim. The evidence of such power and control is that the victim submits to sexual demands on the part of the offender. “The offender controls his victim through verbal threats, intimidation with a weapon, or physical force, and this provides the offender with a reassuring sense of power, security, strength, mastery, and control. In this fashion, he compensates for underlying feelings of inadequacy, vulnerability, and helplessness.” This kind of offender “shows little skill in negotiating interpersonal relationships and feels inadequate in both sexual and nonsexual areas of his life.” The researchers add, “Having few other avenues of personal expression, sexuality becomes the core of his self-image and self-esteem. Rape becomes the means by which he reassures himself of his sexual

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adequacy and identity, of his strength and potency.” For this class of assailant, the offenses become repetitive and compulsive, with a possible escalation in the amount of aggressive force used in the assault. Groth et al. explain, “The power rape may be precipitated by some perceived challenge from a female or threat from a male which activates the offender’s feelings of inadequacy and insecurity.” To this end, sexual assault is the vehicle through which the offender can express his identity, and demonstrate his potency, mastery, strength, and dominance—all the while denying any feelings of inadequacy, rejection, and vulnerability. In cases of sadistic rape, the researchers say, aggression is eroticized, and the assailant derives immense satisfaction in the sexual abuse of his victim: Sexuality and aggression become intertwined into a single psychological experience: sadism. The assault itself appears ritualistic and usually involves bondage and torture . . . The rape experience for this type of offender is one of intense and mounting excitement. He finds pleasure in the victim’s torment, anguish, distress, and suffering. His assault is deliberate, calculated, and premeditated. The victim is stalked, captured, abused, and in extreme cases, murdered.

Groth et al. assert that all types of rape are motivated by power: controlling the victim (the power rape); hurting the victim (the anger rape); and degrading and destroying the victim (the sadistic rape). “Anger, power, and sexuality are evident in all rapes, but the role each of these components plays and the pattern in which they interface may vary from one offender to another,” they write. “Rape is a complex, multidetermined act which, in addition to expressing anger and asserting control, also serves to compensate for feelings of helplessness, to reassure the offender about his sexual adequacy, to assert his identity, to retain status among peers, to defend against sexual anxieties, to achieve sexual gratification, and to discharge frustration.” The researchers point out that the by-products of rape—the victim’s etiology—including the life-threatening nature of the assault, the victim’s helplessness and loss of control, and being the target of her assailant’s rage, might constitute the offender’s pathology. They write, “The clinical typology offers one approach to differentiating offenders with regard to identification, disposition, treatment planning, and prognosis.”

6.3.4 DECONSTRUCTING

A

RAPE CASE

It is essential for forensic nurses and examiners to understand the dynamics of a sexual assault case. A sweeping study conducted by Riggs et al. (2000) analyzed 1,076 cases of sexual assault to determine whether rates of sexual assault are increasing, and if demographics and char-

acteristics are changing. The researchers endeavored to describe victim, assailant, assault, and treatment characteristics for sexual assault victims and to provide descriptive data on the evidentiary examination. The researchers collected data on all sexual assault victims presenting to an urban Level 1 trauma center from January 1992 to December 1995 for treatment and evidentiary examination. Data from crime laboratory records were retrospectively reviewed. Presenting after a sexual assault were 1,112 patients; a total of 1,076 (97 percent) patients consented to the medical and evidentiary examination and were enrolled in the study. Age of the patients ranged from 1 to 85 years, with 96 percent (1,036) female and 4 percent (41) male victims. In 80.1 percent of cases, the assailant acted alone; however, 10.3 percent of cases involved two assailants, and as many as 12 assailants were documented in one case. The number of assailants was greater than 1 in 20 percent (208) of cases, and the assailant was a stranger only 39 percent (409) of the time. Men were significantly (31.5 percent) more likely than women (18.6 percent) to face multiple assailants. The assault occurred in the victim’s home in 20.9 percent of cases, in the assailant’s home in 20.8 percent of cases, and in automobiles in 14.6 percent of cases. The assailant was someone the victim knew or had an established relationship with in 37.8 percent of cases. The assailant was a first-time acquaintance in 23.6 percent of cases, and a stranger in 38.7 percent of cases. Physical force was used in 80 percent (817) of reported assaults, and in 27 percent (275) of cases a weapon was present. Vaginal intercourse was involved in 83 percent (851) of female victims. Oral assault was involved in 25 percent (271) of all cases, and anal penetration was involved in 17 percent (178) of all cases. Overall, general body trauma was seen 67 percent (621) of the time, and genital trauma occurred in 53 percent (388) of cases. Twenty percent (147) of patients had no trauma noted on examination. Sperm were noted on the ED wet mount in 13 percent (93) of the victims, and of the 612 cases with both ED sperm data and crime laboratory semen data available, evidence of sperm and semen were found 48 percent (296) of the time by either. Sixty percent of all women received treatment to prevent pregnancy, and 88 percent of all victims agreed to take prophylaxis for sexually transmitted disease (STDs). Of the 12 percent who opted not to receive prophylaxis, most were likely to have been assaulted by a known assailant. The researchers concluded, therefore, that health care professionals should be aware that general body trauma is common, that the assailant is often someone known to the victim, and that evidence of semen is commonly found by the crime laboratory even when it is not found in the ED analysis of a wet mount. (A more detailed discussion

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of patterns of genital injury in sexual assault victims can be found later in this chapter.) A number of other characteristics of rape cases have been documented in the medical literature. Grossin et al. (2003) endeavored to describe the victim, the assailant, assault characteristics for sexual assault victims according to the time between the last sexual assault and the examination, and to provide descriptive data on medico-legal findings. Their study was based on 418 examined victims of sexual assault during the year 1998. Victims were referred from investigating police authorities. All examinations were performed with the use of colposcopy by physicians with special training in forensic medicine. Two groups of victims were defined: a first group of victims examined in the ED within 72 hours after the last sexual assault, and a second group of victims examined after 72 hours. About 86 percent of the cases were female victims. The average age of the cases of the first group was 22.4 years. Conversely, 76 percent of the victims examined after 72 hours were under the age of 15 years. Vulnerability was present in 31 percent of the cases examined in the ED, including disabled and pregnant victims. Sexual assault happened once in 87 percent of the cases of the first group and in 64 percent of the cases of the second group. The victim’s home was the most frequent place of sexual assault (35 percent of the cases of the first group and 56 percent of the cases of the second group). The assailant was a stranger in 51 percent of the cases of the first group. In the second group of the victims, the assailant was a family member in 58 percent of the cases (the father in 30 percent of the cases). There was a single assailant in the majority of the cases for the two groups. Threats were used by the assailant on 66 percent of the victims examined in emergency and 33 percent of the cases of the second group. Grossin et al. (2003) reported that the type of sexual assault was penetration in the majority of the cases for both groups. Vaginal, oral, and anal penetration were involved in 55 percent, 23 percent, and 13 percent, respectively, of the cases of the first group. General body trauma was found in 39.1 percent of the cases examined in the ED and in 6.3 percent of the cases of the second group. Genital trauma occurred in 35.7 percent of the cases in the first group and in 19.5 percent of the cases in the second group. Hymenal, vulvo-vaginal, and anal lesions were found in 11 percent, 20 percent, and 7 percent of the cases, respectively, examined in the ED. Toxicological analysis was performed in 14.3 percent of the cases examined in the ED. In 47 percent of the tested cases, a drug was detected. Cytology was performed in 61.5 percent of the cases examined in the ED. Detection of spermatozoa occurred in 30.3 percent of these cases. Feldhaus, Houry, and Kaminsky (2000) acknowledged various studies suggesting significant rates of female sexual assault; the majority of them remain unreported, and few victims receive medical care. Feldhaus et al. undertook a study to determine lifetime prevalence rates of

Forensic Nursing

sexual assault in an ED population and to assess reporting patterns to police, physicians, and social service agencies. A verbally administered survey was given to all female patients during four-hour randomized periods in an urban Level 1 trauma center. Four hundred forty-two women were eligible; 360 (81 percent) of them agreed to participate. The lifetime prevalence rate of sexual assault was 39 percent. Ninety-seven women (70 percent) were older than 15 years at the time of the assault. Of these, 97 assaults occurred in adulthood; 49 (52 percent) reported assault by an acquaintance, family member, or friend; 28 (30 percent) by a stranger; and 17 (18 percent) by a partner. Forty-five (46 percent) women reported the crime to the police, 42 (43 percent) sought medical care, and 23 (25 percent) contacted a social service agency. Reporting patterns for victims assaulted by a stranger versus those assaulted by a partner were: reported to police, 79 percent versus 18 percent; received medical care, 70 percent versus 29 percent; and contacted a social service agency, 30 percent versus 24 percent. The researchers concluded that lifetime female sexual assault rates in ED populations are significant. Fewer than half of victims report the assault to the police or seek medical care. Women assaulted by a partner are significantly less likely to report the sexual assault to police or seek medical care. Walch and Broadhead (1992) assert that state and federal statistics have described a lower incidence of rape and child abuse than is suggested by community prevalence rates. Victims of sexual assault can experience numerous short-term and long-term effects on psychosocial and physical health. They add that these victims tend to use medical services more than nonvictims and are also more likely to seek medical care than mental health services. Their study sought to determine the prevalence of sexual victimization in a family practice setting. Of 416 women, 405 agreed to participate. Of 147 family-practice patients, 47.6 percent reported some type of contact sexual victimization during their lifetimes; 25.2 percent reported rape or attempted rape. Of 258 student health service patients, 57 percent had experienced contact sexual victimization, and 28.7 percent reported rape or attempted rape. Of those who reported unwanted sexual contact, 30 percent of the family practice patients felt they would not be comfortable discussing the experience with medical personnel, and 44.9 percent of the student health service patients would not feel comfortable doing so. The researchers concluded that women with a history of unwanted sexual contact might be common in family practice and student health settings. Although treatment can be beneficial, many of these patients are not comfortable discussing their experiences with medical personnel. The authors say that their findings suggest that there is potential benefit in obtaining a sexual victimization history as part of routine care, but further research is necessary to assess the clinical benefit of such an approach.

Sexual Assault

6.4 HEALTH-RELATED CONSEQUENCES OF SEXUAL VIOLENCE Regardless of the type or prevalence of sexual violence, health care providers should be aware of the numerous health-related consequences. The medical literature has thoroughly documented the myriad health consequences of sexual violence, including short- and long-term physical and psychological effects. Resnick (1997) characterizes the following sequelae of sexual violence: 1. Physical injuries can lead to chronic sequelae, such as heart attack, stroke, syncope, fractures from falling, dislocated joints, torn muscle tissue, or a loss of dexterity. Acute health problems, such as STDs, can also develop into chronic infection, dysfunction, or systemic disorders. 2. Assault-related generalized stress can impair functioning of the immune, endocrine, or autonomic systems, increasing the likelihood of the victim’s contracting infectious diseases. 3. Either assault-related stress or assault-related emotional problems might increase the risk of engagement in unhealthy behaviors, such as smoking, excessive alcohol or drug use, poor diet, lack of sleep, or insufficient physical exercise. These behaviors could contribute to future health problems or immune system disorders and might lead to chronic mental health problems. 4. Assault-related inappropriate health care utilization places victims at higher risk of needing additional restorative treatment.

6.4.1 PHYSICAL IMPACTS Individuals who have experienced sexual assault can suffer a range of nongenital and genital injuries. Nongenital injuries can include bruises and contusions; lacerations; ligature marks on ankles, wrists, and neck; anal or rectal trauma; and pattern injuries such as handprints, finger marks, belt marks, and bite marks. Genital injuries are most commonly seen in the posterior fourchette, the labia minora, the hymen, and the fossa navicularis. The most common types of genital injuries include tears, abrasions, bruising, redness, and swelling. Additionally, victims of sexual assault are at increased risk of unwanted pregnancy, STIs, pelvic pain, pelvic inflammatory disease, and urinary tract infections. Goodman, Koss, and Russo (1993) and Koss and Heslet (1992) studied acute physical injuries following completed rape, including nongenital physical injury as well as vaginal tearing. Geist (1988) found that more than half of the rape victims seen in EDs have vaginal and perineal trauma, and 15 percent have significant

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vaginal tearing. Goodman et al. (1993) found that approximately 5 percent of reported rapes of women in childbearing years result in pregnancy. Victims are also at risk for any of 15 STDs that reportedly occur in 3 percent to 30 percent of victims of sexual violence. Kilpatrick, Edmonds, and Seymour (1992) found that most victims of sexual violence report that they did not receive standard medical care after their assault. Young, Bracken, and Goddard (1992) found that only half of all sexual assault victims who receive emergency treatment return for a follow-up examination.

6.4.2 PSYCHOLOGICAL IMPACTS Although manifestations of psychological effects vary from individual to individual, the medical literature recognizes these symptoms as being common in sexual assault victims: rape trauma syndrome; PTSD; depression; social phobias; anxiety; increased substance use or abuse; suicidal behavior; and other physical distresses such as chronic headaches, fatigue, sleep disturbances, recurrent nausea, eating disorders, menstrual pain, and sexual difficulties. 6.4.2.1 Rape Trauma Syndrome Many victims of sexual violence experience rape trauma syndrome (RTS), which is defined as “the stress response pattern of . . . a person who has experienced sexual violence” (WHO, 2003). RTS can be manifested in somatic, cognitive, psychological and behavioral symptoms, and usually consists of two phases: the acute phase and the long-term phase. The acute phase is a period of disorganization beginning immediately after the rape and persisting for several weeks. During the acute phase, a person usually experiences strong emotional reactions and might present with physical symptoms. Emotional responses tend to be either expressed or controlled; they can be expressed as anger, fear, or anxiety on one end of the spectrum, or as shock and numbness on the other. The acute reaction is rooted in a fear of physical injury, mutilation, or death, and once the victim comes to terms with the violent event, he or she might experience mood swings, as well as intense feelings of shame, humiliation, degradation, guilt, embarrassment, self-blame, hopelessness, anger, and fear of another attack. The long-term phase is one of reorganization, beginning several weeks after the event, where the victim reorganizes his or her life in an adaptive or maladaptive way. Factors influencing how well a victim recovers include the age of the survivor, specific personality traits, his or her life situation, the circumstances surrounding the sexual assault, and the degree of support he or she receives from loved ones (WHO, 2003).

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6.4.2.2 PTSD Victims of sexual violence frequently experience symptoms of PTSD, which appears to be more common in persons who were threatened with a weapon or extreme physical force, those assaulted by strangers, and in cases where physical injuries were inflicted. Symptoms of PTSD include the following: •

• • • • • •

Reliving the experience through nightmares, flashbacks, and recurrent, intrusive thoughts of the attack Self-imposed isolation from family, friends, and peers Increased drug or alcohol use Engaging in high-risk behaviors Avoiding places, activities, or people that remind victims of the assault Disassociation from the attack Hypervigilance about one’s personal safety and security

Studies indicate that the psychopathological sequelae of rape are prevalent and long term. Rothbaum and associates (1992) found that fully 90 percent of rape victims met symptom criteria for PTSD within two weeks of the rape, and about 50 percent continued to meet PTSD criteria three months later. Individuals who evinced relatively severe initial distress were more likely to meet PTSD diagnostic criteria at the three-month point. Kilpatrick et al. (1987) found that PTSD was present 17 years after assault in 16.5 percent of cases. Resnick et al. (1993) noted that 11 percent of women who were victims of rape at any point in their lives actively met diagnostic criteria for PTSD at the time of assessment, and rape victims were 6.2 times more likely to develop PTSD than were women who had not been raped. Rates of PTSD in women following nonsexual assault are similar to those following rape. Kessler et al. (1995) found that post-sexual-assault rates of PTSD were 48 percent, and that post-physical-assault rates of PTSD were 39 percent. Resnick et al. (1993) found the rates of postrape PTSD to be 32 percent, compared with 38.5 percent following physical assault. Koss and Heslet (1992) suggest that persistent physiological arousal, as seen in PTSD cases, might lead to actual physical impairments. McFarlane et al. (1994) discovered high rates of cardiovascular, respiratory, musculoskeletal, and neurological symptoms in men with PTSD. Litz, Keane, and Fisher (1992) established an association between persistent arousal and illness in a study of Vietnam veterans. Pitman (1993) also suggested that cue-specific physiological arousal, such as heart rate, is elevated in association with PTSD in response to trauma-related visual images. Resnick (1997) says that long-term follow-

up studies with postassault samples of men and women are needed to explore other potential health effects of persistent physiological arousal. “Post-traumatic stress disorder is very real,” asserts Candice DeLong, a former psychiatric nurse and a 20-year veteran agent with the FBI: It has been studied extensively by Ann Wolbert Burgess, RN, PhD. She literally wrote the book on it, and is one of the finest researchers in the country. But I wouldn’t have had to read her book to know that PTSD exists. Someone breaks into the victim’s home and he or she never gets over it. When it comes to PTSD, similar symptoms are manifested whether the individual is a soldier on the battlefield or someone who is at home having dinner with the family and someone comes in and ties everyone up, threatens them, and steals the Picasso painting right off of the wall. The same common denominator among all types of violent crimes is the victim’s fear of loss of life as well as a loss of control. You are not in control of your life when someone is threatening you. Then factor in the humiliation of sexual assault or other violent physical contact . . . people suffer from PTSD who go through a lot less trauma than a rape victim does. There is absolutely no doubt in my mind that it exists and that health care providers must recognize and deal with it.

In one study, Resnick (1997) found that more than half of 29 sexual assault victims who were assessed within hours after the rape reported that they experienced physical reactions of nausea or abdominal distress, rapid heart rate, shortness of breath, shaking, sweating, and choking sensations during the rape. Resnick, Kilpatrick, Dansky, and Freedy (1992) determined that physiological indicators of panic, such as dizziness, chest pain, and shortness of breath, were a major predictor of immediate trauma reactions reported by men and women who had experienced violence. Initial reactions, such as abdominal distress or pain, might become learned conditioned responses to environmental fear triggers, leading to longer term health problems that might include chronic pain syndrome or irritable bowel syndrome (IBS). Leserman (1998) assessed the prevalence of physical and sexual assault histories among 239 female gastroenterology patients and found that 67 percent had a positive history of assault. Irwin et al. (1996) studied 50 patients seeking treatment for IBS who had high rates of PTSD and other psychiatric diagnoses. Falsetti, Lydiard, Gibbs, and Resnick (1997) studied data from 3,911 men and women who were assessed for symptoms of IBS, violence histories, mental health diagnoses, and patterns of using medical services. They discovered that IBS prevalence was 2.8 percent. These findings support the reported presence of gastrointestinal symptoms during acute trauma and as a component of the physiological alarm response.

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In addition to IBS, other medical complaints in connection with victimization history have been studied. Walker and Stenchever (1993) reviewed studies of chronic pelvic pain and other physical complaints in association with physical and sexual assault. They concluded that the data supported a stronger association between sexual assault and chronic pelvic pain than between pain and other types of assault. A history of physical assault or a compound history of both sexual and physical assault, however, might be associated with general chronic pain syndromes. Physical pain at the time of sexual or physical assault tends to be associated with the specific locations of later chronic pain.

6.4.3 HARMFUL BEHAVIORS TRIGGERED ASSAULT

BY

SEXUAL

Following a violent assault, victims might increase their use of substances to reduce symptoms of fear, anxiety, and depression. Kilpatrick et al. (1987) say that extreme levels of painful affect produced by assault can cause individuals to engage in behaviors that effectively diminish negative emotions, such as escaping by abusing alcohol or drugs. In addition to its direct causal role in mortality, alcohol appears to play a facilitative role in many more deaths and injuries from accidents or violence. Jurkovich et al. (1992) and Rivara, Jurkovich, and Gurney (1993) reported that almost half of trauma victims presenting to the ED had been using alcohol. Alcohol has been detected in 63 percent of homicide victims, 49 percent of nonintentional injury fatalities, 35 percent of suicides, and 14.4 percent of natural deaths, according to Rutledge and Messick (1992). Yates, Hadfield, and Peters (1987) reported that 60 percent of victims of violence who presented to an ED had been using alcohol. In a study of 1,770 adult ED patients, Cherpitel (1993) found that individuals with violence-related injuries were more likely to be under the influence of alcohol, to report episodes of heavy drinking, to have experienced significant negative consequences of drinking, and to have received treatment for an alcoholrelated problem. Buss, Abdu, and Walker (1995) determined, on the basis of self-report and toxicology screens, that 70 percent of seriously assaulted individuals seeking hospital treatment were under the influence of either drugs or alcohol at the time they were attacked, and 60 percent reported that their assailants were drinking or using drugs. Breslau et al. (1991) noted that the likelihood of victimization in individuals with alcohol problems was 1.47 times that of individuals without substance use problems; the likelihood of trauma and victimization was 1.79 times as likely for individuals with drug problems. Kessler et al. (1995) found that alcohol and drug abusers were about 1.5 times as likely to experience traumatic events as nonusers. Long-term effects of child abuse have been found

to influence increased alcohol and drug use. Miller et al. (1987) discovered that 67 percent of alcoholic women reported having experienced sexual assault during their childhoods, in contrast to 20 percent of nonalcoholic women. Polusny and Follette (1997) found that 27 percent to 37 percent of victimized women reported lifetime alcohol-related problems, compared with only 4 percent to 20 percent of nonabused women. Burnam, Stein, and Olding (1988) observed that twice the proportion of assaulted adults developed alcohol abuse relative to nonvictimized adults. Victimization also affects rates of drug use. Polusny and Follette (1997) noted that 14 percent to 31 percent of women who were sexually abused as children exhibited drug-related problems later in their lifetimes, compared with 3 percent to 12 percent of controls. In a study of male and female victims, Burnam et al. (1988) observed that 18 percent of assault victims but only 2 percent of matched controls reported drug abuse. Kilpatrick et al. (1997) found that the likelihood of continued drug use two years after an assault nearly doubled in newly assaulted or previously assaulted women, even after controlling for age, race, education, and first-time drug use. An increased number of eating disorders has been found among both women and men with histories of sexual assault (Laws & Golding, 1996). Dansky (1997) found that the incidence of rape and physical assault was higher in respondents with bulimia nervosa (26.6 percent evinced a history of rape, and 26.8 percent evinced a history of physical assault) compared with respondents without bulimia (13.3 percent with past rape, and 8.5 percent with past assault). In a study of both genders, Laws and Golding (1996) reported that sexual assault victims were about twice as likely as nonassaulted individuals to weigh less than 85 percent of their normal body weight, to have one or more symptoms of anorexia nervosa, and to experience a sudden weight change. Because this was a cross-sectional study, we do not know the sequence of events. The researchers add, however, that repeated sexual victimization and assault by a parent were associated with an increased likelihood of having one or more symptoms of anorexia. Increased promiscuity and having unprotected sex have been observed among victims of sexual violence. McGinnis and Foege (1993) studied a group of rape victims in a one-year follow-up and discovered that a history of assault and exposure to rape were associated with increased HIV risk behaviors and rates of STDs. In 430 sexually active college women, Harlow et al. (1993) found that victimization by sexual or physical assault was a significant predictor both of the partner’s risk characteristics and of unprotected vaginal intercourse. Conversely, Resnick (1997) writes, “Sexual activity often becomes aversive as a result of its association with high autonomic arousal during a rape, and rape victims frequently use

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drugs or alcohol to cope with conditioned anxiety during sexual activity. This maladaptive coping style may impair an individual’s ability to take appropriate precautions to avoid the risk of HIV and may also reduce the likelihood of avoiding truly dangerous situations.” Resnick indicated that use of drugs or alcohol during sex was associated with increased rates of unprotected sex. Elliott, Mock, and Briere (2004) examined the prevalence and impact of adult sexual assault (ASA) in a stratified random sample of the general population. Among 941 participants, ASA was reported by 22 percent of women and 3.8 percent of men. Multivariate risk factors for ASA included a younger age, being female, having been divorced, sexual abuse in childhood, and physical assault in adulthood. Childhood sexual abuse was especially common among sexually assaulted men and women (61 percent and 59 percent, respectively). ASA victims were more symptomatic than their nonassaulted cohorts on all scales of the Trauma Symptom Inventory, despite an average of 14 years having passed since the assault. Assaulted men reported greater symptomatology than assaulted women, whereas nonassaulted men reported less symptomatology than nonassaulted women.

6.5 VICTIMS’ UTILIZATION OF MEDICAL SERVICES Inappropriate or inadequate use of services by victims is an area of concern to some researchers. Resnick (1997) writes, “Misinterpretation of a variety of post-trauma signs of physiological arousal or actual post-trauma physical impairment may also play a significant role.” Golding et al. (1988) assessed the use of mental and physical health services in a community population, looking at the actions of 2,560 individuals who had been screened for a lifetime history of sexual assault. Seventeen percent of women and 9 percent of men reported being victims of sexual violence. The use of mental and medical health services in the preceding six months was significantly greater among the women with a history of sexual assault: 17.8 percent reported using mental health services, and 59.7 percent reported using medical services. The corresponding rates of mental and medical health service use among women in the sample who were not sexually assaulted were 9 percent for mental health services and 44.1 percent for medical services. Conversely, among women in the study who used medical services recently, the rate of histories of sexual assault was 20.8 percent, compared with 12 percent among medical service nonusers. The researchers found that individuals without private insurance increased their use of the services more than those who were insured, so not having medical insurance did not prevent increased usage among those with sexual assault histories. These data indicate

Forensic Nursing

that health perceptions and functional impairment lead to higher medical use among victims, regardless of who pays for the services. Koss, Woodruff, and Koss (1990) and Koss, Koss, and Woodruff (1991) studied 2,291 women in a health maintenance organization (HMO) who completed a mail survey to assess stressful events, physical and sexual assault victimization, and health perceptions; 241 of the female victims also participated in in-person interviews. The researchers discovered that demographic variables, stressful life events, and crime victimization were significant predictors of how one perceived one’s health status. Data from clinic records of 68 of the interviewed women with histories of assault, rape, or other crimes that occurred while they were covered by the health plan indicated that 93 percent made at least one physician visit in the year after the reported crime. All made physician visits again in the year following the assault. Koss and Woodruff (1991) described results of interviews with 390 women who belonged to an HMO. Of the 390, 316 had experienced some type of crime. The women reported nonvictimization, 19 percent; noncontact crime, 13 percent; single incident crimes without rape, 23 percent; completed rape, 24 percent; and multiple assaults, 21 percent. The women with histories of sexual or physical assault reported poorer health overall and poorer health habits. The greatest distress was reported on gynecological symptoms, including sexual dysfunction. Multiply victimized women made 6.9 visits to a physician per year, whereas nonvictimized women averaged 3.5 visits annually. Kimerling and Calhoun (1994) studied the medical use and health perceptions associated with violence in a study of 115 rape victims and a comparison group of 87 women for a 1-year postrape period. Rape victims reported physical symptoms, including rapid heart rate, tension headaches, stomachaches, skin problems, menstrual symptoms, weight changes, and allergies that decreased over the course of the year. In addition, rape victims displayed significantly elevated psychological distress throughout the year. Despite this diminished symptomatology, the rape victims’ use of medical services was significantly greater than that of nonvictims at four months and one year following the assault. Interestingly, Kiecolt-Glaser and Glaser (1992) discovered that the utilization of mental health services was not different for the victims and nonvictims. Kimerling and Calhoun (1994) theorized that the low rates of use of these services could be the result of misidentifying psychological distress as physical illness. Many of the reported physical symptoms were also symptoms of anxiety and depression. Victims might also engage in health-related behaviors that could cause them long-term harm. Resnick (1997) states, “Although several studies indicate that assault tends

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to increase use of health care services, additional data indicate that women with histories of sexual abuse or assault may be less likely to engage in positive health care behaviors, such as obtaining regular Pap smears.” Young et al. (1992) found that that almost 40 percent of urban women raped in the past year had at least one STD, compared with 19 percent of women of similar socioeconomic demographics. “This finding,” Resnick (1997) says, “is consistent with a relative lack of adaptive medical care available to these women. Thus, lack of resources or avoidance of distress or anxiety may lead to failure to obtain needed preventive medical care.” Poor health behaviors in general have been associated with victimization or posttrauma psychological distress, including fatalism, becoming careless about health care, drinking more alcohol, smoking, drug use, and careless eating habits.

6.6 THE HEALTH CARE RESPONSE TO SEXUAL VIOLENCE 6.6.1 EXPERIENCES

IN THE

ER

Violence has a significant impact on the physical and psychosocial health of millions of Americans every year. Because women are so often the victims of violence, it is essential that women who present to EDs for even minor trauma be thoroughly evaluated. ED staff must be aware of the types of injuries most likely resulting from violence, and the victim must be asked about the cause of the trauma to determine if it is the result of violence and further evaluation is required (Sheridan, 1993). When violence such as rape is identified, trained staff need to be available to provide services. Only in 1992 did the guidelines of the JCAHO first require emergency and ambulatory care facilities to have protocols on rape, sexual molestation, and domestic abuse (Bobak, 1992). In chapter 1 we examined the concept that the ER is the portal for the majority of cases, both forensic and not. This portal often determines if a forensic case will be handled properly or not. In December 2003, the Texas Association Against Sexual Assault (TAASA) assembled A Report on the Level of Care for Sexual Assault Patients in Texas Hospital Emergency Rooms. It paints an engrossing picture of how these victims are dealt with in a state that sees its share of sexual assault and abuse cases annually. Authored by Mimi Garcia, BA, and Torie Hilton, MEd, the TAASA study was conducted to assess the level of care for sexual assault patients in Texas hospital ERs, specifically pertaining to the patient’s care in the hospital before, during, and after a forensic medical examination. All hospitals with emergency rooms, including children’s hospitals and members of the Catholic Health Association, were asked to participate in a survey that included measures of geographic data; routines for treating sexual assault patients before, during, and after medical examinations; hospital policies

and protocols; and training of health care providers. Four hundred twelve surveys were distributed and 107 were returned (a 26 percent response rate). The average number of beds in participant hospitals was 147. Fourteen percent of these hospitals described themselves as public, 26 percent as for-profit, and 60 percent as nonprofit. Additionally, 62 percent of hospitals indicated they were in rural locations and 39 percent in urban locations. Finally, the hospitals see an average of 4.6 sexual assault patients per month. The TAASA report presented the following results: Before the Exam. Privacy is extremely important to sexual assault patients, as details of the assault are often embarrassing to discuss. Because of this concern TAASA recommends that a private area be provided for sexual assault patients to discuss the assault with law enforcement and medical professionals. Eighty-two percent of hospitals in this survey indicated a private area was provided, 19 percent only when possible. Because the evidence collected through the exam might be used in a trial, it is important to maintain a proper chain of custody. This is easier when the exam occurs in a dedicated exam room. Seventy-three percent of hospitals indicate these were provided, 21 percent did not provide them, and 6 percent provided them when possible. Texas state law allows a support person, including a rape crisis center advocate, in the exam room for support and comfort if the patient desires. Seventy-six percent of hospitals indicated that they gave the patient the option for contacting a rape crisis center advocate, 7 percent said no, and 16 percent indicated there was no rape crisis center in their area. Treatment of Sexual Assault Patients. Some communities have developed a system in which one hospital in their area treats sexual assault patients. In this survey, 60 percent of hospitals treat the sexual assault patients and 40 percent stabilize and transfer. STIs, including HIV, are a common concern of rape survivors. It is standard care to provide information about STIs, including HIV, to sexual assault patients. Treatment is dependent on the circumstances of the patient. The study found that 89 percent of hospitals provided information and treatment for STIs, and 70 percent provided this care for HIV. Pregnancy is another common concern. Eighty-four percent of hospitals indicated they provide information on the risks of pregnancy. Emergency contraception can prevent pregnancy if taken within 72 hours after the assault. It is the standard of care to inform and offer female sexual assault patients emergency contraception, yet only 23 percent of Texas ERs met this standard of care. Seventy percent of ERs provide, at a minimum, information, but 13 percent do not inform sexual assault patients of emergency contraception unless the patient asks. Hospital Policies Regarding the Treatment of Sexual Assault Patients. There should be a minimum level of care for sexual assault patients in Texas ERs. This minimum

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level can be indicated by the presence of hospital policy or the presence of policies and protocols published by outside entities. Seventy-eight percent of hospitals reported having a specific policy for the treatment of sexual assault patients. Sixty-five percent reported having a copy of the Texas Evidence Collection Protocol on file. Thirty-one percent reported having a copy of the ACEP Guidelines for the Care of Sexual Assault Patients. Free, confidential services are provided to all rape survivors through the local rape crisis center. Services include hospital accompaniment, individual and group counseling, criminal justice accompaniment, and advocacy. Survivors should be assisted in contacting their local rape crisis center. Seventy-seven percent of hospitals reported referring patients for rape crisis center care, 8 percent did not refer patients, and 15 percent indicated that a rape crisis center is not available. Training Hospital Staff for the Treatment of Sexual Assault Patients. SANEs are nurses who are specially trained to conduct sexual assault exams sensitively, accurately, and as objectively as possible. The sexual assault exam usually lasts two to three hours and consists of a detailed set of steps in the evidence collection process. Training is highly recommended, as the evidence collected will be scrutinized in a court of law. Thirty-four percent of hospitals reported having a SANE program and 66 percent reported not having the program. Although a SANE program is ideal, many hospitals do not have the program and depend on their regular ER staff to perform the sexual assault exams. Typically speaking, only one fourth of ER physicians and nurses have specific training in the treatment of sexual assault patients, with less than 5 percent of respondents indicating that it is a requirement for employment. Findings also indicate that physician assistants and nurse practitioners seldom receive training on sexual assault examinations.

6.6.2 PHYSICIANS

AS

PART

OF THE

EQUATION

Before the advent of the specially trained SANE—a concept that is addressed later in this chapter—physicians in the ER were expected to provide the sexual assault evidentiary examination. Lacking proper training in medicolegal protocols, the examinations these physicians provided were not always up to the standards expected today by and from SANEs. A number of studies point to the varying degrees of success physicians have had in providing medico-legal services to victims. ED records are an important source of injury surveillance data. However, documentation regarding intentional assault has not been studied and could be suboptimal. Houry, Feldhaus, and Nyquist (1999) analyzed physician documentation of assailant, site, and object used in intentional assault. The researchers reviewed retrospectively the ED log of an urban Level 1 trauma center to identify

eligible patients presenting consecutively in November 1996. From the ED log, 1,483 patients were identified as possible study subjects; 1,457 (98 percent) charts were located and reviewed and 971 (67 percent) met inclusion criteria. Of these, 288 (30 percent) cases resulted from intentional assault. In 67 percent of patients, there was no documentation of the identity of the assailant. For 13 percent of cases, there was no documentation regarding the object or force used in the assault. In 79 percent of cases there was no documentation regarding the site of assault. For 24 cases (8 percent), the assailant was documented as an intimate partner or former partner. Police involvement in these cases was documented 54 percent of the time, despite the fact that this state mandates police reports for cases of acute partner violence. Social service involvement and shelter referrals were documented in less than one fourth of domestic violence cases. The researchers concluded that although the ED commonly treats patients who have been assaulted, basic surveillance data are often omitted from the chart. Structured charting might provide more complete data collection. Du Mont and Parnis (2004) reported on findings from a population-based study of sexual assault physicians who are responsible for both the health care of sexually assaulted persons and for conducting forensic medical examinations on them for the purpose of collecting corroborative evidence to aid in legal proceedings. Selfadministered questionnaires were distributed to the 100 physicians attached to sexual assault care and treatment centers across the province of Ontario, Canada. The questionnaires were focussed on exploring their relative commitment to two assessment priorities: the collection of forensic evidence for the courts and the provision of medical care. Although most of the 31 physicians replying expressed satisfaction with their participation in the legal arena, a substantial proportion indicated that although they believed medical care to be the most important part of their work, evidence collection and court appearances were the most time-consuming. In addition, more than four fifths admitted to having deviated from the standard protocol used for evidence collection, based on the belief that a particular procedure or information item might either emotionally or legally harm the victim or her or his case. The researchers write, “We suggest that the implications of these findings point to a possible ambivalence toward the evidentiary dimension of the dual role of the sexual assault physician.”

6.6.3 EMERGENCY PHYSICIANS ADDRESS OF SEXUAL VIOLENCE

THE ISSUE

In 1999, the ACEP published the 134-page handbook, Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient. A quick look at the guidelines’ content is prudent, as the handbook appears to embrace

Sexual Assault

the contributions of forensic nurses, or at the very least, the work of SANEs. The handbook addresses clinical considerations including the following: 1. Identification of sexual assault or sexual abuse. Recent sexual assault is usually defined as within 72 hours; however, this interval can be extended, as technology such as DNA analysis advances. Because some drugs can be found in the serum up to 1 week after ingestion, for the patient with drug-facilitated rape, the collection of evidence can be performed up to 96 hours later. If the patient is in the out-of-hospital setting and the sexual assault is recent, the patient should be encouraged to go immediately to the ED, local rape crisis center, or other designated facility suitable for an evidentiary examination to collect physical evidence. The patient should be instructed to not engage in activities that might destroy important evidence that can be used to identify the perpetrator, such as urinating, defecating, vomiting, douching, removing or inserting a tampon, wiping or cleaning the genital area, bathing, showering, gargling, brushing teeth, smoking, eating, drinking, chewing gum, changing clothes, or taking medications. Nonevidentiary examinations might or might not be emergent. Nonemergent cases can be referred to appropriate local resources for collection of appropriate evidence or for follow-up care once the patient’s immediate needs are met. 2. Clinical evaluation. The handbook says: Policies and procedures for the evaluation and management of the patient with the complaint of sexual assault should be established by all sexual assault evaluation facilities. SANE programs are an excellent option for acute and chronic sexual assault evaluations, because they standardize the sexual assault evaluation and collection of evidence. Special attention and supervision must be provided if resident physicians are involved in sexual assault evaluations to best ensure timely, efficient, and standardized treatment.

The handbook emphasizes that life-threatening injuries must be treated first. Once stabilized, the patient should be placed into a private room as soon as possible. A specially trained individual who can provide crisis intervention, such as a rape crisis advocate, mental health professional, social worker, or pastoral caregiver, should be available for emotional support. If desired by the patient, a friend or relative can be present. Throughout the encounter, privacy, safety, and confidentiality must be ensured.

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Ideally, the information in the medical record should be available to outside authorities only with the consent of the patient. However, disclosure of the medical record might be mandated by law in some jurisdictions. In most states, the sexually assaulted patient is not required to report the assault to law enforcement authorities. In contrast, in many states, medical personnel are required by law to report all cases of sexual assault. Most states mandate the reporting of sexual abuse of children to police or to the child protection agency. However, in many jurisdictions, police coordinate and oversee the collection of evidence. Thus, if they determine that sexual assault has not occurred or if the patient is uncertain about pressing charges, no evidence is collected. Informed consent or refusal should be obtained for each of the following components of the sexual assault evaluation: • • • • • •

Medical evaluation and treatment Reporting the crime Performing a physical examination Photo-documentation Evidence collection Transfer of evidence to law enforcement personnel

In many jurisdictions, hospitals are not required by law to perform examinations on suspected perpetrators without a court order or alternative means of legally mandating such an examination. Persons placed under arrest do not have the right to refuse an examination for the collection of evidence if the officer has a court order. Because states vary in requirements, check your local statutes. In the evidentiary examination, the examiner should prevent cross-contamination of evidence by changing gloves whenever it could occur. Clearly document all findings. 1. Before the patient undresses, place a clean hospital sheet on the floor to be a barrier for the collection paper. 2. Allow the patient to remove and place each piece of clothing being collected in a separate paper bag. Handle all clothing with gloved hands to prevent contamination of evidence. 3. Simultaneously identify the presence of any physical injury, biological evidence, or foreign debris, but do not disturb. 4. Recover any trace evidence, including sand, soil, leaves, grass, and biological secretions. Note the body location of the collection; identify moist secretions. 5. Note all injuries by documenting the location, size, and complete description of any trauma, including bite marks, strangulation, or areas of

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6.

7.

8. 9.

point tenderness, especially those occurring around the mouth, breasts, thighs, wrists, upper arms, legs, back, and anogenital region. Perform appropriate photo-documentation of collection sites before collection, as well as documentation of other suspect areas. Recover moist secretions with a dry swab. Look for areas of debris and dried secretions on the skin; flake them off onto folded paper. Recover any remaining material on these areas with a swab moistened with one drop of water (tap water is acceptable). Document the Tanner Stage of the patient and describe the level of physical maturity. Follow these sexual assault evidence collection instructions: • Toluidine blue dye can be used to identify minor external genital and anal injuries, but it might cause discomfort in prepubertal children. • When the vaginal examination is performed, the speculum should be lubricated with tap water because other lubricants might affect test results and decrease sperm motility. A vaginal speculum is never used in prepubertal children without general anesthesia. • When drug- or alcohol-facilitated sexual assault is suspected, blood and urine should be collected. If alcohol was ingested, use the law enforcement blood alcohol collection kit or collect three fluoride tubes. Check with local law enforcement for the kit. If a drug was ingested within 36 hours of examination, collect three full fluoride tubes of blood and 100 ml of nonprepped, first-void urine. If a drug was ingested more than 36 hours before the examination, collect 100 ml of nonprepped, first-void urine. Package each item separately, label and seal, and initial each package. • A colposcope can be used as an adjunctive examination tool. Ano-genital examination findings are enhanced through illumination, magnification, and photo documentation. • The collection of known samples from the patient might be indicated (buccal smear, blood, or hair). Depending on laboratory preferences, these samples can be collected later.

Regarding chain of custody, the examiner should document all historical and physical findings. Properly seal and initial all specimens and label with the following information:

• • • •

Hospital name, patient name, and patient identification number Date and time of collection of evidence Description and location of the body part of origin of the evidence Name and signature of the person collecting the evidence

All transfers of custody of evidence must be accountable by keeping a written record of the name and signature of the person receiving the evidence, and the date and time of the transfer. The handbook says examiners should consider offering the following interventions depending on the circumstances: 1. Antibiotic prophylaxis for STDs 2. Hepatitis B immunization if the patient has not been previously immunized 3. HIV prophylaxis based on risk assessment of exposure 4. Pregnancy prevention Finally, the ACEP guidelines say that the patient should be given referrals to local resources for follow-up counseling and advocate services. The patient should be referred for follow-up examinations in two weeks, three months, and six months for evaluation of pregnancy and STDs. Despite the ACEP’s acknowledgment of the issue and its handbook of protocol, many nurses have observed physicians’ reluctance to work with sexual assault victims. This might be why the SANE program has increasing relevance and importance. According to Ledray (1999), “The primary mission of a SANE program is to meet the needs of the sexual assault victim by providing immediate, compassionate, culturally sensitive, and comprehensive forensic evaluation and treatment by trained, professional nurse experts within the parameters of the individual’s state nurse practice act, the SANE standards of the International Association of Forensic Nurses (IAFN), and the individual agency policies.” Ledray adds that SANE programs should adopt specific goals, such as the following: • •

• • • •

To assess, document, and treat injuries To provide timely, thorough, and professional forensic evidence collection, documentation, and preservation of evidence To evaluate and treat prophylactically for STDs To evaluate pregnancy risk and offer prevention To provide crisis intervention To appropriately refer victims for immediate and follow-up medical care and counseling

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•

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To enhance the ability of law enforcement agencies to obtain evidence and successfully prosecute sexual assault cases

6.6.4 NURSES

AS

PART

OF THE

EQUATION

In chapter 3, we examined the fact that in 1992, JCAHO first required health care institutions to have protocols on rape, sexual molestation, and domestic abuse (Bobak, 1992). Five years later, JCAHO required these health care institutions to train their staff members to use criteria to identify possible victims of physical assault, rape, or other sexual molestation, domestic abuse, and abuse or neglect of older adults and children. (JCAHO, 1997). Although the JCAHO does not specifically stipulate that a forensic nurse perform these duties, it is clear that the accreditation agency expects a well-trained individual to provide appropriate and complete services to victims. The stage has been set for the work of forensic nurses, and in the arena of sexual assault cases specifically, these nurses are known as SANEs. Efforts of the SANE are magnified when the nurse works within a SART model, which encompasses the SANE (or other health care provider), an advocate, a law enforcement officer, and a prosecutor. Other members might include domestic violence victim advocates, state crime laboratory personnel, clergy, and social services staff. Several studies confirm the idea that these nurse examiners are well suited to work with victims of violence. Du Mont and Parnis (2003) compared nurses who had participated in a SANE program to nurses who had not participated in the program on their opinions and practices in relation to the collection of forensic evidence. Self-administered surveys were distributed to all SANEs and nonSANEs employed in sexual assault care centers in Ontario, Canada. The researchers found that SANEs were more likely to indicate that certain samples, items, or questions should not be taken or asked as a regular part of the forensic examination. They were less likely to perceive the presence of physical injuries and semen or sperm as being “extremely important” to a positive legal outcome. Finally, more SANEs reported experiencing dilemmas with respect to their dual roles as caregivers and evidence collectors. Amey and Bishai (2002) examined two aspects of ED treatment received by women who experienced sexual assault: administration of emergency contraception to prevent pregnancy and screening and treatment for STDs. The researchers analyzed seven years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). They found that the number of rapes per year reported in the NHAMCS data is highly consistent with the number of forcible rapes reported by the FBI. Results showed statistically significant differences in patients who received screening on the basis of age and also suggested

that the same difference exists for STD medications received. They added that accounting for differences in screening and medications by age does not completely explain why a large portion of the patients are neither screened nor receive STD medications.

6.6.5 A NURSE’S ISSUE: EMERGENCY CONTRACEPTION Although Linda Ledray, RN, PhD, LP, FAAN, believes forensic nurses have made great strides, there are major pockets of controversy and complacency that should be rooted out. One such pocket is a refusal to administer emergency prophylaxis to rape victims, an issue that she says wasn’t handled appropriately in the recently released National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents, published by the U.S. Department of Justice Office on Violence Against Women in September 2004 (and discussed later in this chapter). “I worked on that protocol, but there were administrative and political limitations,” she says. We were told as clear as can be that if we suggested, recommended, or even brought up the subject of emergency contraception, it wouldn’t get published. Familyplanning issues are as close as we could get. It should say that every rape victim has to be offered emergency contraception and that she can make the decision if she wants it. I also think the Centers for Disease Control and Prevention (CDC) has limited us; there is absolutely no reason they should be testing for STDs in the ER, and the CDC is very naive if they think the rape shield laws are going to keep positive results out of the courtroom. I feel like we all sold out to the current administration but it would have happened anyway. We fought over the wording in it. There were versions that were much worse than the final version; I’m not sure some people are happy with it.

Ledray is understandably concerned about emergency contraception issues. Health care providers are hit-andmiss about informing victims about the availability of contraception. Ledray (2001) writes: In the past, forensic examiners tested for STIs in the ED and then again at follow-up. The rationale was that if a victim was negative initially, and positive on follow-up, the assailant, if apprehended, could be tested as well. If he was positive for the same STI this could then link him to the crime. Because there are so many variables that could account for a positive STI test, this has not been useful forensic evidence and is no longer recommended practice for adult and adolescent examinations. It is still recommended for ongoing child sexual abuse.

STIs are, however, a concern for victims from a clinical perspective and must be addressed as a part of the initial examination, Ledray adds. Ledray (1999) found that

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although 36 percent of rape victims presenting to the ED stated their primary reason for coming was concern about having contracted an STI, the actual risk is low. The CDC estimates the risk of rape victims getting gonorrhea is 6 percent to 12 percent, chlamydia risk is 4 percent to 17 percent, syphilis risk is 0.5 percent to 3 percent, and the risk of HIV is less than 1 percent. STI testing is very expensive and time-consuming for the survivor, who must return two or three times for each test; according to Blair and Warner (1992), most victims do not return. According to Ledray (1999), 25 percent of the survivors seen in the ED returned for the initial STI follow-up visit. Tintinali and Hoelzer (1985) found that only 15 percent returned. The researchers were able to contact 47 percent of those who had not returned for follow-up and they found an additional 11 percent of these went elsewhere for medical follow-up; however, only 14 percent told the physician they saw for follow-up about the rape. Most clinicians recommend prophylactic treatment for STIs. According to Blair and Warner (1992), except in child sexual abuse cases, cultures taken need not be handled as evidence because they are not used in court. Yuzpe, Smith, Percival, and Rademaker (1982) stated that the risk of pregnancy from a rape is approximately 2 percent to 4 percent. Although this is a low risk, some might argue, pregnancy is a victims’ concern that should be addressed at the time of the initial examination, even if the treating medical personnel or the medical facility does not support termination of an existing pregnancy. The National Conference of Catholic Bishops agreed that, “A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medication that would prevent ovulation, or fertilization.” A look at the medical literature is in order. Holmes (1999) writes, “Sexual assault is a common occurrence that carries significant physical and mental health morbidity. Some of the most common concerns expressed by sexual assault victims can be allayed by addressing the risks of rape-related sexually transmitted infections. Although exact risks cannot be accurately quantified, it is important that health care professionals provide counseling as well as prophylaxis and/or treatment as indicated.” Holmes, Resnick, Kilpatrick, and Best (1996) attempted to determine the national rape-related pregnancy rate and provide descriptive characteristics of pregnancies that result from rape. A national probability sample of 4,008 adult American women participated in a threeyear longitudinal survey that assessed the prevalence and incidence of rape and related physical and mental health outcomes. The national rape-related pregnancy rate was calculated to be 5 percent per rape among victims of reproductive age (12–45); among adult women, an estimated 32,101 pregnancies result from rape each year.

Forensic Nursing

Among 34 cases of rape-related pregnancy, the majority occurred among adolescents and resulted from assault by a known, often related perpetrator. Only 11.7 percent of these victims received immediate medical attention after the assault, and 47.1 percent received no medical attention related to the rape. A total of 32.4 percent of these victims did not discover they were pregnant until they had already entered the second trimester; 32.2 percent opted to keep the infant, whereas 50 percent underwent abortion and 5.9 percent placed the infant for adoption; an additional 11.8 percent had spontaneous abortion. The researchers concluded that rape-related pregnancy occurs with significant frequency, is a cause of many unwanted pregnancies, and is closely linked with family and domestic violence. They write, “As we address the epidemic of unintended pregnancies in the United States, greater attention and effort should be aimed at preventing and identifying unwanted pregnancies that result from sexual victimization.” Merchant, Keshavarz, and Low (2004) examined the extent of HIV postexposure prophylaxis (PEP) provision in a New York City pediatric ED after the release of emergency prophylaxis guidelines. Using logs of the sexual assault and violence intervention advocacy program, the researchers identified patients who had been evaluated for sexual assault in the hospital’s pediatric ED from January 1999 to December 2000. These patients’ medical records were reviewed retrospectively for details of their sexual assault and the medical treatment they received in the ED. Of 25 patients identified from the hospital’s affiliated sexual assault and violence intervention advocacy program logs, 14 female adolescents had received HIV PEP. Each patient had sustained forced vaginal intercourse; 64 percent of the victims knew their assailant, but none knew his HIV status. No patients received HIV PEP within the optimal one-hour prescription time, but none presented within the one-hour window. Eighty-six percent presented more than 12 hours after the event and 42 percent presented more than 24 hours after the assault. HIV PEP was ordered an average of 218 minutes after the patient presented to the ED, and patients received drugs an average of 58 minutes after they were ordered. All but one patient received a three-drug regimen. The researchers encourage efforts to expedite HIV PEP provision in the ED, such as educating ED practitioners on its proper use, and making HIV PEP drugs available for direct dispense from the ED. Keshavarz, Merchant, and McGreal (2002) undertook a study to determine ED practitioner willingness to offer emergency contraception following sexual assault and consensual sex, and to compare responses of practitioners from states whose laws permit the refusal, discussion, counseling, and referral of patients for abortions with those of practitioners from states without these laws. Using a structured questionnaire, a convenience sample of ED practitioners attending a national emergency medicine

Sexual Assault

meeting was surveyed. The 600 respondents were 71 percent male, 29 percent female; 34 percent academic, 26 percent community, 33 percent resident physicians; and 7 percent nurse practitioners and physician assistants. Many respondents (88 percent) were inclined to offer emergency contraception to those sexually assaulted by unknown assailants. More practitioners said they were willing to offer emergency contraception if the assailant was known to be HIV-infected rather than if the assailant had low HIV risk factors (90 percent vs. 79 percent). More respondents would prescribe emergency contraception after sexual assault than consensual sex (88 percent vs. 73 percent). The rates of willingness to offer emergency contraception were the same for practitioners in states with abortionrelated conscience clauses and those from other states. Wiebe, Comay, McGregor, and Ducceschi (2000) reports that the the sexual assault service operated by the Children’s and Women’s Health Centre of British Columbia, in partnership with the Vancouver General Hospital Emergency Department, started offering HIV prophylaxis in November 1996 to patients presenting to the ED after a sexual assault. In the first 16 months of the program, a total of 258 people were seen by the service, of whom 71 accepted the offer of HIV prophylaxis. Only 29 continued with the drug treatment after receiving the initial five-day starter pack, and only eight completed the full four-week treatment regimen and returned for their final follow-up visit. Patients at highest risk for HIV infection, including those who had penetration by an assailant known to be HIV-positive, were more likely to accept prophylaxis and more likely to complete the treatment than those at lower risk. Compliance and follow-up were the main problems with implementing this service. Service providers found it difficult to give the information about HIV prophylaxis to traumatized patients. The researchers reported that following this program evaluation, the service changed its policy to offer HIV prophylaxis only to people at high risk of HIV infection. They said that this targeting of services is expected to make the service providers’ jobs easier and to make the program more cost-effective while still protecting sexual assault victims against HIV infection. Unintended pregnancy is a major medical, social, and public health problem. Emergency contraceptive pills can prevent 75 percent to 85 percent of unintended pregnancies if administered within 72 hours of intercourse. Abbott, Feldhaus, Houry, and Lowenstein (2004) performed a study to measure knowledge, attitudes, practices, and perceived needs about emergency contraception in a sample of women seeking care at an ED. The sample consisted of women presenting to an inner-city ED during an eightweek study period. Women who were aged 18 to 45 years, English speaking, and not critically ill and who presented during 56 randomly generated four-hour time blocks were eligible. Trained research assistants administered a 20question survey that included questions on current sexual

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and contraceptive practices and knowledge, acceptance, and preferences about postcoital contraception. Two hundred thirty-two women met eligibility criteria; 158 (68 percent) women agreed to participate. The participants’ mean age was 30 years. Twenty-five percent were married, 49 percent had never married, and 25 percent were separated or divorced. Fifty-two percent reported at least one previous unintended pregnancy; 28 percent had one or more previous elective abortions. Of women who had been sexually active in the past month, half reported unprotected intercourse during that time. Among all respondents, 122 had heard of emergency contraception as a way of preventing pregnancy after unprotected intercourse. Of these respondents, one fourth to one half did not have enough knowledge to use emergency contraceptive pills effectively. Fifty-seven percent of women were willing to use emergency contraceptive pills in the future, and 16 women said they would consider a change in regular contraception to emergency contraceptive pills if widely available. The researchers concluded that sexually active women seeking ED care have high rates of unintended pregnancy and abortion. There is broad acceptance of emergency contraceptive pills to prevent pregnancy, but knowledge of availability, timing, and proper use is limited. Emergency contraceptive pills are a safe, effective, and low-cost primary preventive and emergency care intervention, and information about their use should be made available to ED patients. Patients should be advised, however, not to abandon their use of barrier or other traditional contraceptives. Myles et al. (2000) conducted a retrospective review of charts of sexual assault survivors who were offered PEP between April 1998 and November 1999 at San Francisco General Hospital. The total cost of PEP medications was also computed. Overall, the researchers noted that one third of the 367 sexual assault survivors chose to initiate PEP. Men who were anally raped are at the highest risk for HIV transmission and were most likely to initiate PEP. Among women, on the other hand, those who were non-White and homeless were less likely to accept PEP. In the context of cost, the total per-person cost of medication dispensed during the study period ($65 per person offered PEP) is comparable to other medications offered routinely following sexual assault, such as azithromycin for chlamydia prophylaxis ($43 per treatment). However, the researchers said there was no definitive evidence that PEP is effective in preventing HIV seroconversion after sexual assault. They suggested that in developing rational policy recommendation for offering HIV PEP after sexual assault, further studies are needed to better delineate the rates of HIV seroprevalence among sexual assailants, the efficacy of PEP after sexual exposure, and the psychological benefits or harm incurred by the sexually assaulted patients.

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Forensic Nursing

Gibb, McManus, and Forster (2003) assessed whether antibiotic prophylaxis should be offered to women after sexual assault by considering acceptability of prophylaxis, follow-up attendance rates, and the prevalence of STIs in these women. A retrospective case review of female survivors of sexual assault attending the Rose Clinic at Ambrose King Centre in the Royal London Hospital between January 1, 1997 and May 31, 1999 was carried out. All women were screened for STIs using standard investigation methods; antibiotic prophylaxis was offered within two weeks of the assault, and the antibiotic regimens were followed as recommended. The women were invited to attend for results at two weeks and offered a further screening at three months postassault. Bacterial vaginosis was present in 32 percent of the women screened, chlamydia trachomatis was identified in 8 percent, and none tested positive for Neisseria gonorrhoeae. Of the 25 women who were offered antibiotic prophylaxis, 88 percent accepted. Follow-up attendances were 57 percent at two weeks and 30 percent at three months. Antibiotic prophylaxis was acceptable to women. Among recent rape victims, follow-up rates are low, as confirmed by this study. These factors support the use of antibiotic prophylaxis after sexual assault. The researchers found a high prevalence of STIs among women in this study, and added that more research is required with respect to this aspect of the work and to consider the cost–benefit analysis of antibiotic prophylaxis. According to the National Conference of State Legislatures, there are seven states that currently have statutes related to emergency contraception: •

•

•

California: Code 2704.13–2704.16 (2003–2004) authorizes a pharmacist to initiate emergency contraception drug therapy in accordance with standardized protocols developed by the pharmacist and an authorized prescriber acting within his or her scope of practice. Hawaii: Rev. Stat. 461-1 allows pharmacists working in collaboration with a physician and with the appropriate training to initiate emergency contraception oral drug therapy. Illinois: Rev. Stat. ch. 110, 1-106 (2002) finds that FDA-approved emergency contraception can significantly reduce the risk of pregnancy of taken within 72 hours after the sexual assault,. The law also finds that providing emergency contraception to rape victims in a timely manner can significantly reduce the trauma of rape. The law requires hospitals providing services to alleged sexual assault survivors to develop a protocol that ensures that each survivor of sexual assault will receive medically and factually accurate and written and oral information about emergency contraception, the risks

•

•

•

•

associated with the use of emergency contraception, and a description of how victims can be provided emergency contraception. The law requires hospitals to submit a plan to provide hospital emergency services to alleged sexual assault survivors. Iowa: Code 144.29A (2003) requires that a pregnancy termination report include information on the method used for the induced termination of a pregnancy, including the use of mifepristone. Maine: Rev. Stat. Ann. Tit. 32, 13821-13825 (2003) allows a pharmacist to initiate emergency contraception drug therapy in collaboration with an authorized prescriber, provided that the pharmacist completes an emergency contraception training program. The pharmacist is also required to provide the recipient of the drug therapy with a standardized fact sheet. New Mexico: Stat. Ann. 16.19.26.9 authorizes a pharmacist to administer emergency contraception drug therapy in accordance with protocols established by the board of pharmacy. The statute also requires that the pharmacist complete a course in emergency contraception drug therapy. Washington: Rev. Code Amm. 70.41 (2002) relates to emergency care for victims of sexual assault. The law declares that it is essential that all hospital ERs provide emergency contraception as a treatment option to any woman who seeks treatment as a result of a sexual assault. The law requires hospitals providing emergency care to victims of sexual assault to provide medically and factually accurate information and emergency contraception at the hospital, orally inform victims of their option to be provided emergency contraception at the hospital, and provide emergency contraception immediately to each victim who requests it. The law mandates the development of informational materials relating to emergency contraception for the prevention of pregnancy in rape victims for distribution in all ERs.

In January 2005, the CDC announced new federal guidelines for the use of antiretroviral drugs to prevent HIV infection after exposure to HIV through sexual intercourse, sexual assault, injection drug use, or accidents. “Using antiretroviral drugs after exposure is an important safety net to prevent HIV infection in certain cases,” says Ronald O. Valdiserri, MD, MPH, deputy director of the CDC’s National Center for HIV, STD and TB Prevention. “But the drugs are not a substitute for abstinence, mutual

Sexual Assault

monogamy, or consistent and correct condom use, and should not be viewed as a quick fix” (CDC, 2005). The new guidelines recommend use of the approach, called nonoccupational postexposure prophylaxis (NPEP), only for patients who seek treatment no more than 72 hours after a high-risk exposure with a person known to be infected with HIV. Treatment should be initiated as soon as possible after exposure and continued for 28 days. The new guidelines update Department of Health and Human Services (HHS) guidance issued in 1998, at which time data were not sufficient to recommend for or against the NPEP approach. Since then, new data from human and animal studies, case reports, and documentation of the approach’s use in several countries, including the United States, have provided evidence to support its use. The guidance includes specific recommendations for clinicians when making decisions about use of the approach. When potentially exposed persons seek care within 72 hours of exposure but don’t know the HIV status of the person who was the possible source, the guidance encourages clinicians to evaluate the risks and benefits on a case-by-case basis. When a person seeks care more than 72 hours after exposure or when HIV exposure risk is low, NPEP is not recommended. Use of the drugs is also not recommended for people whose behaviors result in frequent, recurrent exposures to HIV. The potential benefits of using antiretroviral drugs for NPEP also must be weighed against the patient’s individual circumstances and the potential risks of the medication, including the possibility of serious side effects and ability to follow a daily regimen of taking several drugs. People who are frequently at risk of exposure to HIV, such as those who have HIV-infected sex partners and rarely use condoms, or injection drug users who often share equipment, would benefit more from intensive risk-reduction interventions than from NPEP. PEP has been recommended for health care workers exposed to HIV since 1996 and in observational studies has been associated with an 80 percent reduction in the risk of infection. Any three-drug combination of antiretroviral medications recommended by HHS can be used as NPEP, except those containing nevirapine. When used under conditions similar to the NPEP approach, nevirapine has been associated with severe reactions and liver damage. The CDC cites a study of sexual assault survivors in Sao Paolo, Brazil. Women who sought care within 72 hours after exposure were treated for 28 days with either zidovudine and lamivudine (for those without mucosal trauma) or zidovudine, lamivudine, and indinavir (for those with mucosal trauma or those subjected to unprotected anal sex) for 28 days. Women were not treated if they sought care later than 72 hours after assault, if the assailant was HIV-negative, or if a condom was used and no mucosal trauma was seen. Of 180 women treated, none seroconverted; of 145 women not treated, four (2.7 per-

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cent) seroconverted. Although these studies demonstrate that NPEP might reduce the risk for infection after sexual HIV exposures, participants were not randomly assigned, and sample sizes were too small for statistically significant conclusions. In a study of rape survivors in South Africa, of 480 initially seronegative survivors begun on zidovudine and lamivudine and followed up for at least six weeks, one woman seroconverted. She had started taking medications 96 hours after the assault. An additional woman, who sought treatment 12 days after assault, was seronegative at that time but not offered NPEP. At retesting six weeks after the assault, she had seroconverted and had a positive polymerase chain reaction result. According to the CDC (2005), surveys of clinicians and facilities indicate a need for more widespread implementation of guidelines and protocols for NPEP use. In a survey of Massachusetts ED directors, 52 percent of facilities had received NPEP requests during the preceding year, but only 15 percent had written NPEP protocols. Similarly, in a survey of Massachusetts clinicians, approximately 20 percent had a written NPEP protocol. Among pediatric emergency medicine specialists surveyed throughout the United States and Canada, approximately 20 percent had a written policy about NPEP use, but 33 percent had prescribed it for children and adolescents; different prescribing practices were reported. In a survey of 27 European Union countries, 23 had guidelines for occupational PEP use, but only six had guidelines for NPEP use. Although the estimated per-act transmission risk from unprotected exposure to a partner known to be infected with HIV is relatively low for different types of exposure, different nonoccupational exposures are associated with different levels of risk. The highest levels of estimated peract risk for HIV transmission are associated with blood transfusion, needle sharing by injection drug users, receptive anal intercourse, and percutaneous needlestick injuries. Insertive anal intercourse, penile–vaginal exposures, and oral sex represent substantially less per-act risk. According to the CDC, a history should be taken of the specific sexual, injection drug use, or other behaviors that might have led to, or modified, a risk for acquiring HIV infection. Eliciting a complete description of the exposure and information about the HIV status of the partners can substantially lower (e.g., if the patient was the insertive partner or a condom was used) or increase (e.g., if the partner is known to be HIV-positive) the estimate of risk for HIV transmission resulting from a specific exposure. In addition to sexual and injection drug use exposures, percutaneous injuries from needles discarded in public settings result in requests for NPEP with a certain frequency. Although no HIV infections from such injuries have been documented, concern exists that syringes discarded by injection drug users (e.g., for whom the HIV infection rate is higher than that for diabetics) might pose

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a substantial risk. However, these injuries typically involve small-bore needles that contain only limited amounts of blood, and the viability of any virus present is limited. In a study of syringes used to administer medications to HIVinfected persons, only 3.8 percent had detectable HIV RNA. In a study of the viability of virus in needles, viable virus was recovered from 8 percent at 21 days when the needles had been stored at room temperature; less than 1 percent had viable virus after one week of storage at higher temperatures. Another category of transmission has special significance for the SANE. Bite injuries represent another potential means of transmitting HIV; however, HIV transmission by this route has been reported rarely, according to the CDC (2005). Transmission might theoretically occur either through biting or receiving a bite from an HIVinfected person. Biting an HIV-infected person, resulting in a break in the skin, exposes the oral mucous membranes to infected blood; being bitten by an HIV-infected person exposes nonintact skin to saliva. Saliva that is contaminated with infected blood poses a substantial exposure risk. Saliva that is not contaminated with blood contains HIV in much lower titers and constitutes a negligible exposure risk. Because of the emotional, social, and potential financial consequences of possible HIV infection, clinicians should handle NPEP evaluations with the highest level of confidentiality. Confidential reporting of STIs and newly diagnosed HIV infections to health departments should take place as dictated by local law and regulations. For cases of sexual assault, the CDC says that clinicians should document their findings and assist patients with notifying local authorities. HIV test results should be recorded separately from the findings of the sexual assault examination to protect patients’ confidentiality in the event that medical records are later released for legal proceedings. Certain states and localities have special programs to provide reimbursement for medical therapy, including antiretroviral medication after sexual assault, and these areas might have specific reporting requirements. When the sexual abuse of a child is suspected or documented, the clinician should report it in compliance with state and local law and regulations. Potential HIV exposures in children occur most often by accident (e.g., needlesticks in the community, fights, or playground incidents resulting in bleeding by an HIVinfected child) or by sexual abuse or assaults. In a review of charts from one year in the pediatric ED of one hospital, 10 children considered for NPEP were identified (six because of sexual assault and four because of needlestick injury). Eight began taking NPEP, but only two completed the four-week course, according to the CDC (2005). An analysis of 9,136 reported AIDS cases in children identified 26 who were sexually abused with confirmed or suspected exposure to HIV infection.

Forensic Nursing

The American Academy of Pediatrics has issued NPEP guidelines for pediatric patients. In addition, HHS pediatric antiretroviral treatment guidelines provide information about the use of antiretroviral agents in children. For young children who cannot swallow capsules or tablets and to ensure appropriate dosing for drugs that do not have capsule or tablet formulations that allow pediatric dosing, drugs for which pediatric formulations are available might need to be prescribed. Adherence to the prescribed medications will depend on the involvement of, and support provided to, parents or guardians. Use of NPEP for sexual assault survivors has been widely encouraged both in the United States and elsewhere, according to the CDC (2005). Sexual assault is relatively common among women; 13 percent of a national sample of adult women reported having ever been raped (60 percent before age 18), and 5 percent reported having been raped more than once. Sexual assault is not uncommon among men. In one series from an emergency department, 5 percent of reported rapes involved men sexually assaulted by men. Males accounted for 11.6 percent of rapes reported among persons aged older than 12 years who responded to the NCVS in 1999. However, only three documented cases of HIV infection resulting from sexual assault have been published, according to the CDC. In observational studies, HIV infections have been temporally associated with sexual assault. Studies have examined HIV infection rates for sexual assailants; the largest of these, an evaluation of men incarcerated in Rhode Island, determined that 1 percent of those convicted of sexual assault were infected with HIV when they entered prison, compared with 3 percent of all prisoners and 0.3 percent of the general male population, according to the CDC (2005). Sexual assault typically has multiple characteristics that increase the risk for HIV transmission if the assailant is infected. In one prospective study of 1,076 sexual assault cases, 20 percent were attacked by multiple assailants, 39 percent were assaulted by strangers, 83 percent of females were vaginally penetrated, and 17 percent overall were sodomized. Genital trauma was documented in 53 percent of those assaulted, and sperm or semen was detected in 48 percent. In another study, in which toluidine blue dye was used as an adjunct to naked-eye examination, 40 percent of assaulted women (70 percent of nulliparas) had detectable vaginal lacerations, compared with 5 percent of women examined after consensual sex (CDC, 2005). Despite these risks and the establishment of multidisciplinary support services, sexual assault survivors often decline NPEP, and many who do take it do not complete the 28-day course. This pattern has been reported in several countries and several programs in North America. In Vancouver, 71 of 258 assault survivors accepted the fiveday starter pack of NPEP, 29 returned for additional doses, and eight completed four weeks of therapy. Those with

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the highest risk for HIV exposure (i.e., source known to be HIV infected, a homosexual or bisexual man, or an injection drug user) were more likely to begin and complete NPEP. Patients who have been sexually assaulted will benefit from supportive services to improve adherence to NPEP if it is prescribed, and from psychological and other support provided by sexual assault crisis centers. All sexually assaulted patients should be tested and administered prophylaxis for sexually transmitted infections, and women who might become pregnant should be offered emergency contraception (CDC, 2005). Certain illegal behaviors that result in imprisonment (e.g., prostitution and injection drug use) also might be associated with a higher prevalence of HIV infection among prison inmates than among the general population. However, studies indicate that the risk for becoming infected in prison is probably less than the risk outside prison. However, when exposure does occur, because sexual contact and injection drug use are prohibited in jails and prisons, prisoners who have experienced such exposures might be unable or unwilling to report the behaviors to health care providers. According to the CDC (2005), administrators and health care providers working in correctional settings should develop and implement systems to make HIV education and risk-reduction counseling, NPEP, voluntary HIV testing, and HIV care confidentially available to inmates. Such programs will allow inmates to benefit from NPEP when indicated, facilitate treatment services for those with drug addiction, and assist in the identification and treatment of sexual assault survivors.

6.6.6 DEVELOPMENT PROGRAM

OF THE

SANE/SART

It has been demonstrated that every nurse is essentially a forensic nurse, but the discipline of sexual assault examination has perhaps the deepest roots of all forensic nursing specialties. The first concerted effort to address the needs of this patient population came in the 1970s, spearheaded in clinical practice by a nurse in Minneapolis, as well as by a nurse in Boston. Ann Wolbert Burgess is considered to be one of the earliest researchers to systematically examine the needs of sexual assault victims. She developed a pattern of psychological response she called RTS, and has spent an academic career championing a scientific study of rape and sexual violence. During the time Burgess was formulating her theories, Linda Ledray was contemplating how to better serve the victims of rape she saw in her community. Ledray is considered by many to be one of the earliest pioneers of SANE nursing, when in 1976 she created the Sexual Assault Resource Service (SARS) at Hennepin County Medical Center in Minneapolis. Her goal was to develop a nursing-focused health care delivery model that addressed the unmet needs of assault and abuse victims.

Although Ledray might have felt that she was working in a vacuum at the time, she discovered that nurses in other parts of the country, notably Texas and Tennessee, were working to implement more responsive care for sexual assault victims. Realizing that by combining their best practices and innovative approaches they could accomplish more, this small group of nurses met, brainstormed, and eventually created a national organization that came to be known as the IAFN, which championed the fledgling SANE and SART programs in the 1980s. SANE and SART programs weren’t on many people’s radars until the early 1990s. In 1994, the SANE program in Tulsa, Oklahoma was awarded the Innovations in State and Local Government Award from the Ford Foundation and John F. Kennedy School of Government at Harvard University. This honor brought to light the accomplishments of the SANEs and piqued the interest of health care professionals interested in starting programs to address needs in their own communities. The first roll call of SANE programs had taken place three years earlier, when in 1991, the Emergency Nurses Association published the first list of SANE programs in its Journal of Emergency Nursing. It was a short list, numbering just 20, but five years later, the number had climbed to 86. The list was the impetus behind a survey conducted by Ledray to obtain more details about SANE program structure and practice. Of the 59 programs surveyed, three were established from 1976 to 1979, 10 from 1980 to 1989, and 46 from 1990 to 1996. At the time the SANE Development and Operation Guide was being written in 1999 by the U.S. Department of Justice Office for Victims of Crime (OVC), there were approximately 117 SANE programs in the United States. Today, Ledray estimates there are more than 400. Prior to the creation of the modern structured sexual assault response program, such exams were a hit-or-miss proposition. Victims of sexual abuse—or any kind of violent trauma or abuse, for that matter—were lumped in with the general ED population, made to wait for seemingly endless stretches of time with their cohorts. When their turn finally came, they were treated with indifference by physicians pressed for time. Cursory examinations were conducted, and crucial steps in the evidentiary exam process weren’t “invented” yet. The impetus to develop SANE programs began with nurses, other medical professionals, counselors, and advocates working with rape victims across the country. It was obvious to these individuals that the services to victims were inadequate, and not at the same high standard of care provided to other patients presenting in the ED (Holloway & Swan, 1993; O’Brien, 1996). A number of researchers (Holloway & Swan, 1993; Sandrick, 1996; Speck & Aiken, 1995) documented sexual assault victims’ long waits for care in the ED because medical personnel viewed their injuries as being less severe than those of other patients.

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During their wait, which ranged from four to as long as 12 hours, victims were prohibited from eating, drinking, or urinating, for fear of losing evidence, just to meet with health care providers who were insufficiently trained to perform medicao-legal exams. Lenehan (1991), Yorker (1996), and Tobias (1990) found that among staff that had been adequately trained, it was common for health care providers not to complete a sufficient number of exams to maintain their level of proficiency. In most cases, Lenehan (1991) found the only physician available to do the vaginal exam was male, and although roughly half the victims were unconcerned about the gender of the examiner, for the other half, this was extremely problematic. Ledray (1999) stated, “Even male victims often prefer to be examined by a woman, as they too are most often raped by a man and experience the same generalized fear and anger toward men that female victims experience.” “When I got into this, there was no such thing as forensic nursing or the SANE program,” Ledray says: Essentially, victims were coming into the ER, waiting eight or 12 hours to be seen, and no one wanted to see them, no one wanted anything to do with them. As well, no one had a clue about forensic aspects, nor did they know much about evidence collection either, although they were trying to do something akin to it. The most that ED personnel were doing back then—fighting the battle of who was going to take care of the victim—was collecting swabs to look for sperm. And, of course, treating injuries, but the documentation was just the clinical documentation, there was no forensic component because people didn’t know about the importance of forensics yet. Back then, physicians didn’t know about emergency contraception and actually some still don’t. It amazes me how many think plan B is the abortion pill. In fact, I was doing a training recently that was attended by an OB/GYN doctor who had graduated in 2000, and she had nothing in her training about emergency contraception. Regarding the attitude of the ED physicians, it wasn’t that forensic issues weren’t important, it’s that they didn’t know what to do and they were afraid if they saw the victim they’d have to testify in court; they clearly didn’t want to do that, partially because of the time and partially because they’d be asked about things they probably expected were errors because they didn’t know how to do the procedure. It still amazes me that when ED staff members are doing a rape kit, they are still reading the directions to the procedure while they are doing it. I don’t think there is any other patient for which we would allow that.

Ledray says she has seen the evolution of sexual assault services in the time since she started in the field. It all began when Ledray, a former member of the U.S. military, moved from Germany and came to the Hennepin County Medical Center in Minnesota. I got started in sexual assault issues because I agreed to do an in-service. I was the nurse manager for the psych

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mental health program for Hennepin County, and a nurse in the OB/GYN clinic asked me to do an in-service to help them provide better services to rape victims; at that time, the only referral made after the ED was to the OB/GYN clinic—no mental health referral, no other referrals, and they knew at best, one in four victims was making it there, the others were not making their appointments. That’s when I started looking into how these victims were treated. That was in 1975, and so many years later, I am still trying to figure it out.

“There were grants available to look at rape impact and treatment projects, so I wrote a grant and started the program,” she adds: In order to get the money to start a program, which is what I really wanted, I was forced to do research, and forced to look at what we were doing at our facility and how we were doing it systematically. Much to my surprise, I found out that even the psychological treatment the rape centers were doing—and it was only recently that they began providing services—really wasn’t the best because they weren’t doing research; they were providing services. What everyone thought was the best way to do it clearly wasn’t. That first grant was a six-month pilot study, four-year grant. I started step by step looking at what we were doing, what was effective, and what wasn’t. We had eight different treatment models that we were comparing and over the years, have taken the best, compared it to other things, and kept what we thought was best. If we found something better, we changed over to it. Obviously it was trial and error as much as anything else. And, most importantly, we didn’t listen to people who said it couldn’t be done. Back in the early days, nurses couldn’t testify, do the exam, do research or secure grants. It really was the dark ages, of a sort.

Ledray recalls an early test of her mettle as she pushed for nurses’ rights to participate in the medico-legal process: There was a well-known medical examiner who has since retired, who looked at the results of the evidence of sperm motility phosphotase levels and testified in court about what the levels meant. However, in a meeting at the county attorney’s office, he threatened not to do so if nurses were in court, not physicians. Fortunately, at that point I was finishing up my doctorate degree, so I figured, if he didn’t want to testify, I would. So the prosecutor went ahead with the case.

Ledray says she owes her earliest successes to a unique combination of clinical and scientific research skills: I was a researcher and a clinician and that’s what made it work. I earned my PhD in clinical psychology and personality research from the University of Minnesota. I was doing the research and implementing it, and then I could test it. My staff would see the client, come up with questions, we’d develop a study, test it, and could implement

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the results and take the next step based on that. It was a relatively rare opportunity; usually researchers aren’t clinicians, so they might not ask the right clinical questions, and maybe their results are never implemented, which is unfortunate.

As a part of the grant for the first five years of the SANE program development, Ledray worked as an employee of a separate organization from the Hennepin County Medical Center, the Minneapolis Medical Research Foundation. “The program started seeing patients in 1975, but it was probably in the early 1980s, when the grant was long over and I started publishing the results of the research . . . that’s when I started getting calls from people who needed help with starting a program of their own. The calls were from nurses . . . nurses who were willing to start a SANE program against all odds.” Ledray’s model got a boost, interestingly enough, from physicians who were spreading word of the early SANE model in the 1980s: Hennepin is a teaching institute, so we had physicians who were doing their ER rotation. They would graduate and go to other hospitals, including others in Hennepin County. When a rape victim would come into their ER, they would immediately say, “Call the SANE!” It was because they knew how good of a program it was. Then, I started getting calls from nurse managers, or sometimes a few physicians at other hospitals, wanting more information about the program. It didn’t surprise me, because physicians don’t want to do sexual assault cases. There is no money in it. I have always been somewhat afraid that if or when funding becomes better, the physicians would try to take it back.

Diana Faugno, RN, BSN, CPN, SANE, director of the SART of San Diego North County, says that the need for a SART was evident the day in 1990 when a woman in San Diego was raped and spent nine hours going from hospital to hospital, unable to find a facility that could collect forensic evidence and provide the appropriate level of care. She recalls the early days of her facility’s SANE program and its quest for validation: Our program launched in 1990, but in 1986 we started our child abuse program, which was similar to the SART model; it had a multidisciplinary approach and members included law enforcement, a social worker, and an examiner. Several years later, the police wanted a similar model for adult victims, so the adult response team was started by Patty Seneski, who came over from Phoenix and got trained on the colposcope in the child abuse room. They asked me to join that team in 1991.

Faugno acknowledges how SANE-related issues have evolved over the years:

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Regarding examinations back then, probably the biggest issue was getting DNA from biological samples—something that hadn’t fully arrived yet. We would collect a lot of evidence, but there was a lot that could not be done with it; back then, kits were only kept seven years and then they were tossed—can you imagine that? The evidentiary examination is still basically the same, with forensic nurses looking for evidence, documenting the evidence, and maintaining that chain of evidence.

Faugno remembers the day when examiners only used the colposcope for child-abuse-related cases. “Child abuse investigation has long had a colposcope as part of the investigation and documentation process; its use on adults came later, but its purpose in these cases is as important as ever.” Faugno recalls that some of the earliest findings that were documented by nurse examiners using a colposcope were questioned: I think they might have been suspect because the injury was there, but we would go back and recheck a lot of exams to make sure that what we were seeing truly was the specific trauma we were looking at and not a congenital malformation. What was challenged was the way that the findings were stated in the literature at that time. We certainly know more today than we did back then. I think we categorized injuries; we would list them out: one, two, three, four, five, six, and we didn’t break them down into specific and nonspecific. We have a little more definition, if you will, of that terminology; redness by itself, or swelling by itself are nonspecific and can be caused by many other things.

Genital injuries, a topic of great controversy and misperception, are discussed in greater detail later in the chapter. Faugno says the early sexual assault work was challenging. Sometimes, interaction with physicians and other health care colleagues often was a walk on the tightrope. “Looking back, it was pretty cutting-edge stuff. At the time, ignorance was bliss. I have no recollection that ED physicians didn’t want the nurses to do a focused sexual assault program; I believe they were very happy to get these victims out of the ED and not have to deal with them so they don’t have to go to court.” 6.6.6.1 Demonstrating the Need for the SANE Program In the aforementioned SANE Development and Operation Guide (Ledray, 1999), Kathryn M. Turman, then-acting director of the OVC writes: We know that victims of sexual assault suffer psychological trauma and, all too frequently, long-term health consequences as a result of their victimization. Therefore, providing sensitive health care to victims is critically important

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in the aftermath of a sexual assault. Unfortunately, the traditional model for sexual assault medical evidentiary exams frequently compounds the traumatization of victims. Medical personnel in the emergency room setting often regard the needs of most sexual assault victims as less urgent than other patients in the emergency room. As a result, rape victims may endure long hours of waiting in the public areas of busy emergency rooms. They are not allowed to eat, drink, or even urinate while they wait for a physician to conduct the medical evidentiary exam. Frequently, the physicians or nurses who perform the exams have not been trained in medical evidence collection procedures or do not perform these procedures frequently enough to maintain their proficiency. Some physicians are reluctant even to perform the medical evidentiary exam, knowing that they might be called away to spend a day or more in court testifying or that their qualifications to testify might be questioned due to their lack of training and experience.

The SANE Guide explains that typically, the rape victim faced a time-consuming, cumbersome succession of examiners for one exam, some with only a few hours of orientation and little experience. ED services were inconsistent and problematic. Often the only physician available to do the vaginal exam after the rape was male (Lenehan, 1991). There are also many anecdotal and published reports of physicians being reluctant to do the sexual assault exam for many reasons, including their lack of experience and training in forensic evidence collection (Bell, 1998; Lynch, 1993; Speck & Aiken, 1995), the time-consuming nature of the evidentiary exam in a busy ED with many other medically urgent patients (DiNitto, Martin, Norton, & Maxwell, 1986; Frank, 1996), and the potential that if they completed the exam they were then vulnerable to being subpoenaed and taken away from their work in the ED to testify in court and be questioned by a sometimes hostile defense attorney (DiNitto et al., 1986; Frank, 1996; Speck & Aiken, 1995; Thomas & Zachritz, 1993). This often resulted in documentation of evidence that was rushed, inadequate, or incomplete (Frank, 1996). Many physicians even refused to do the exam (DiNitto et al., 1986). In one case, it was reported that a rape victim was sent home from a hospital without having an evidentiary exam completed because no physician could be found to do the exam. As research became more readily available on the complex needs and appropriate follow-up for rape victims, nurses and other professionals realized the importance of providing the best ED care possible (Lenehan, 1991). For 75 percent of these victims, the initial ED contact was the only known contact they had with medical or professional support staff (Ledray, 1999). Ledray writes, “Nurses also were very aware that while they were credited with ‘only assisting the physician with the exam,’ in reality they were already doing everything except the pelvic exam” (DiNitto et al., 1986; Ledray, 1992a). It was clear to these nurses

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that it was time to reevaluate the system and consider a new approach that would better meet the needs of sexual assault victims. Turman adds, “The services of trained, experienced SANE practitioners help to preserve the victim’s dignity, enhance medical evidence collection for better prosecution, and promote community involvement and concern with crime victims and their families.” Seng and Sanubol (2004) say there are increasing opportunities for nurses to become SANEs, but in rural areas far from established SANE programs, nurses considering becoming SANEs have few opportunities to talk with or observe experienced SANEs to explore the role and determine if they are well suited to forensic work. The researchers sought to learn what the first year in practice was like for members of a new semirural SANE team in terms of role transition and role-specific stress. They conducted interviews with six members of a SANE team three times during their first year in that role. The researchers discovered that the expertise these nurses brought from their backgrounds as emergency nurses, women’s health nurses, and intensive care nurses transferred well and eased their adaptation to the SANE role in a process more akin to role expansion than role transition. They identified comfort working with clients in crisis, acting on their clinical judgment, implementing complex protocols, and adding new skills to their regular nursing role as helpful in their transition to the SANE role. Themes about the first year included the contribution of prior experiences observing or assisting with examinations, concerns that diminished over time, getting used to being on call, using their usual coping skills, getting past the first examination, and finding satisfaction. 6.6.6.2 A Model SANE Program As described by Ledray (1999), a SANE is usually available on call, off premises, 24 hours a day, seven days a week. The on-call SANE is paged immediately whenever a victim of sexual violence enters the health care facility. If the facility’s protocol indicates that an advocate should be called, the staff or SANE also will page the individual who is on call. There are several models of SANE programs. In the hospital-based SANE program model, a victim can enter the health care system by calling local law enforcement who will transport him or her to the hospital ED or SANE exam clinic; by going directly to the hospital ED; or calling a designated crisis line for assistance. During the time it takes for the SANE to respond, which ideally should be less than an hour, the ED or clinic staff will evaluate and treat any urgent or life-threatening injuries. If treatment is medically necessary, the ED staff should treat the patient, always considering and documenting thoroughly the forensic ramifications of the lifesaving and stabilizing medical procedures. If clothes or objects are removed from the victim by the ED staff, care should be

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taken utilizing forensic principles for handling and storage of the physical evidence. If medical necessity dictates treatment prior to the arrival of the SANE, ED staff take photographs following established forensic procedures. However, it is preferable that the SANE take all forensic photographs. When the ED staff determines that the victim does not require immediate medical care, the victim should be taken to a private room adjacent to the ED, which enhances the victim’s sense of safety and security and provides comfort and quiet. If the victim has not yet filed a police report and indicates that he or she wants to do so, a health care provider should contact law enforcement to take the initial report at the hospital. If the victim is upset, and a social worker is available on site, with the victim’s permission, the social worker is called to wait with the victim until the SANE arrives. In the community-based SANE program model, a victim can enter the health care system by calling local law enforcement. They are first triaged for injuries and, if only minor injuries or no injuries are present, they are transported to the community-based SANE facility. If going to the ED of a local hospital on their own, a victim is triaged for injuries, and if there are only minor injuries or no injury present, they are transported to the communitybased SANE program. Victims can also get access by going directly to the community-based SANE program during business hours or by calling the designated crisis line for assistance and receiving a referral to the community-based SANE program. No matter where the program is based, once the SANE arrives, he or she is responsible for completing the entire evidentiary examination, including crisis intervention, STD prevention, pregnancy-risk evaluation and interception, collection of forensic evidence, and referrals for additional support and care. In states with mandatory reporting laws, the SANE is required to follow established protocol for reporting felony crimes, after explaining the process to the victim. Ledray (1999) advises that if the victim has not yet decided if he or she wants to report the incident, the SANE discusses the victim’s concerns and provides information necessary to make an informed decision. If the victim does not want to report at this time, but is unsure if he or she will report at a future date, the SANE should ensure that the victim is aware of his or her options and the limitations of reporting at a later date. The SANE should offer to complete an evidentiary exam kit that can be held in a locked refrigerator for a specified time (usually one month or an appropriate period of time as mandated by state law) in case the victim chooses to report the incident later. If the victim decides not to report and an evidentiary exam is not completed, the SANE still offers prophylaxis to prevent STDs, evaluate the victim’s risk of pregnancy, and offer pregnancy prevention for up to 72 hours postrape. The SANE also should make referrals for follow-up medical care and counseling. When a report is

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made, a complete evidentiary exam is conducted following the SANE program’s protocol. In most programs, the complete exam is conducted within 36 hours of the sexual assault, and an abbreviated exam is completed between 36 and 72 hours postrape—up to 96 hours in some states. (Ledray, 1999) After obtaining a signed consent form, the SANE should conduct a complete examination, including the collection of evidence in a rape kit, further assessment and documentation of injuries, prophylactic care for STDs, evaluation of pregnancy risk and preventive care, crisis intervention, and referral for follow-up medical and psychological care. When the victim is ready to be discharged, the SANE should inquire if the victim would like accompaniment by a family member or friend. Ledray (1999) writes, “Every effort will be made to find a place for her to go where she will feel safe and will not be alone.” 6.6.6.3 A Model SART Program Ledray (1999) writes, “No SANE program can operate in isolation. To be optimally effective and provide the best service possible to victims of sexual assault, the SANE must function as a part of a team of individuals from community organizations.” The answer is the formation of a SART. Ideally, the SART will include representatives from the community who can best help the victims. Members of a SART often include the SANE, law enforcement officer or detective, prosecutor, victim advocate, and ED personnel. The original SART model, developed in California, involves a coordinated response. According to Ledray (1999), “The concept is based on the belief that a team response helps prevent the victim from reporting the account of the assault repeatedly. It also helps prevent confusion among professionals trying to meet the needs of the rape victim as she progresses through the health care and criminal justice systems.” When members of law enforcement go to the scene of a violent sexual incident, they protect the victim from further harm, protect the crime scene evidence, and take a limited statement from the victim to determine if a sex crime was committed. They then call the hospital ED triage, who pages the SANE and the rape advocate on call. When the police and victim arrive at the hospital, the SANE decides if the victim should be directed to the ED for medical evaluation by a physician, or directed immediately to the SANE area for forensic examination. The SANE stays with the victim during any necessary medical evaluation and until he or she is cleared medically and transferred to the SANE examination area. With the advocate present to provide support, the SANE and the police officer or detective conduct an in-depth interview of the victim after briefly conferring to coordinate questioning. Once the interview is completed, the police officer or detective waits outside the exam room while the SANE

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collects the evidence, which is then turned over to law enforcement or locked in a secured area for law enforcement to pick up at a later time. With the victim’s permission, the advocate remains in the exam room to provide support during the exam as well. When the exam is completed, the SANE makes any necessary arrangements for follow-up medical care, and the advocate makes arrangements to contact the victim for follow-up supportive counseling and legal advocacy. Ledray (1999) acknowledges limitations of the SART program, particularly in the area of victim reporting: If the victim is uncertain about reporting, she may feel pressured to report when protocol requires law enforcement personnel to interview the victim before the SANE becomes involved. The advocate will support the victim in whatever decision she makes, even if the decision is not to prosecute. If the victim decides not to report, this also may result in a victim who cannot access health care for STD and pregnancy risk evaluation and prevention. If the victim decides not to report, the hospital care is then typically not paid by the crime victims compensation fund. When the police authorize reimbursement, they are more likely to require that a police report be made. In areas where payment is authorized through another agency, reporting is not necessarily a requirement for payment.

Reimbursement for the evidentiary exam and collection of rape kit contents are discussed elsewhere in this text. 6.6.6.4 Obstacles to the SANE/SART Program Although SANE/SART programs have distinct advantages, Ledray (1999) has assembled from the medical literature a list of the following obstacles these programs face: • •

•

•

• •

The fear of physicians that the SANE would miss injuries in the initial exam (O’Brien, 1996) The concern of physicians that they will still be called to testify in court even though they did not complete the exam (Ledray & Simmelink, 1997) The belief of prosecutors that a physician must conduct the exam for the physical evidence to stand up in the courtroom (DiNitto et al., 1986) The belief of prosecutors that the SANE will not be as credible a witness in court as the physician (Antognoli-Toland, 1985; Ledray, 1992) Inadequate funding (O’Brien, 1996) Narrow interpretation of old laws requiring a physician to collect the evidence for it to be used in court and for the cost of the exam to be reimbursable (Speck & Aiken, 1995)

In the SANE Guide (1999), Ledray addresses these concerns in a systematic fashion:

1. Concerns about cost. Although starting and operating a SANE program requires a financial investment, having a SANE on call might actually be more cost-effective for the facility because it frees both the ED physician and nurse, saving an estimated 20 minutes of physician time and 3.5 hours of ED nursing time, according to Rambow, Adkinson, and Frost (1992). DiNitto et al. (1986) found that SANErelated costs are more modest than the costs in facilities with physicians completing even a portion of the exam; however, actual costs for the physician fee, use of the ED, laboratory fees, and medication costs often exceed the amounts reimbursed by the state. In many cases, if there are no legal restrictions on billing the victim, or no special arrangements are made with the hospital, victims might be charged these additional expenses. 2. Fear of interference. Through the course of their responsibilities, SANEs assist law enforcement and prosecutors in numerous ways. Yorker (1996) has found that as a rule, police officers prefer to work with a few forensically trained nurses, as opposed to dozens of different nurses and physicians in a busy ED, because SANEs know what evidence to collect and how to maintain the proper chain of custody. 3. Concern that the SANE will not perform the exam as well as a physician. Ledray says the reliability of the evidence collected from a rape victim has been of significant concern to other medical and law enforcement personnel. She cites the approach used in the United Kingdom: Until recently, only police surgeons (usually male) were allowed to collect evidence from victims. When a group of female general practice physicians decided they wanted to make their services available, their ability to develop the necessary forensic skills to collect evidence was challenged by the police surgeons. Wright, Wright, and Farnan (1999) report that their persistence has paid off, and they are becoming increasingly accepted for their contributions. Holloway and Swan (1993) say that this was a necessary first step before the police were willing to train nurses for this role in England. Ledray says: The real issue is one of training and experience, not professional background. Just as with any other specialized clinical skill, competency in the collection of forensic evidence and the completion of a sexual assault evidentiary exam entails

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training and experience. It does not necessarily require an advanced medical degree. Unfortunately, most medical and nursing schools do not teach forensic principles. Few physicians or nurses have the opportunity to complete a sufficient number of rape exams to develop or maintain proficiency, even if they have completed the training. A primary advantage of the SANE program is that a dedicated, limited number of nurses complete all of the evidentiary exams in a given hospital or clinic, which enables them to complete an adequate number of exams to develop and maintain proficiency. When Ledray and Simmelink (1997) compared 24 sexual assault evidence kits collected by SANEs to 73 collected by non-SANEs, the SANE kits provided more complete documentation, and the SANEs always maintained proper chain of custody, whereas the others did not. Thirteen (18 percent) of the kits completed by non-SANEs either had no indication of who had collected the evidence or the records were illegible, thus making the available evidence useless. Overall, 48 percent of the non-SANE kits had some break in the chain of custody compared to none of the rape kits collected by SANEs.

4. Concern that the SANE will not be a credible witness in court. “Concerns about SANE credibility are unfounded,” Ledray (1999) writes. “In fact, there are several reports of prosecutors, who were initially concerned, later finding that the SANE is an extremely credible witness in court as a result of her extensive experience and expertise in conducting the sexual assault exam.” Yorker (1996) found that prosecuting attorneys who have worked with SANEs know they can rely on the competence of the SANE as a witness if the case goes to trial, and that the testimony of the SANE is backed up by solid credentials and impressive numbers of victims seen (Lenehan, 1991). 6.6.6.5 The Challenge to Nurse Examiners Some physicians are questioning the quality of the medical record generated by the SANE in his or her documentation of the evaluation and treatment of sexual assault victims who present in the ER, based on the paucity of information that would otherwise validate SANEs’ work. Minshall and Patel (2001) compared medical record documentation practices of SANEs and their medical center to the standards set forth in the medical literature, as reviews by these nurses had resulted in individual institutional protocol revisions and policy changes in an effort to continually improve the quality of care provided (Ledray, 1992a,

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1992b). The researchers knew that a 1995 policy issued by the ACEP states, “As part of ongoing quality management activities, the hospital should establish patient-care criteria for the management of the sexually assaulted patient and monitor staff performance. Emergency department staff should have ongoing training and education in the management of the sexually assaulted patient.” They questioned whether completion of a state-mandated medico-legal recording tool by the SANE is sufficient to meet the medical needs of patients who present to the ED with the complaint of sexual assault. Minshall and Patel drew up a list of various items considered to be essential for comprehensive medical record documentation, drawing from OB/GYN, emergency medicine, and other relevant literature. They retrospectively reviewed the charts of survivors of sexual assault who presented to their 180-bed medical center between January 1996 and November 1998. The facility’s ED, which treats about 55,000 patients annually, treated approximately 200 sexual assault victims annually. Inclusion criteria included being a survivor of recent sexual assault (presenting for evaluation with 72 hours of the assault), managed by a SANE, and being 16 years old or greater. The audit of the medical record included not only review of the state-mandated OCJP 923 form, but also all pertinent material related to that visit, including the face sheet, nursing notes, dictated summaries, laboratory slips, and so on. Elements considered to be essential based on the literature review were not noted within the OCJP 923 paperwork, including historical elements (general medical history, medication allergies, and current medications), physical examination elements (examination of the oral cavity and bimanual examination), and laboratory and disposition elements (obtaining cultures and prophylactic treatment for STDs, testing and prophylaxis for pregnancy, and referral for counseling or other social support measures). Minshall and Patel found that there were 162 cases of sexual assault over the 36-month review period; 127 (78 percent) charts were available for review, 79 (49 percent) of which met inclusion criteria. The most common reasons for exclusion were patient age less than 16 years or survivors were not managed by a SANE. All but one patient were female, and only one male survivor met inclusion criteria. OB/GYN history and pregnancy testing statistics therefore utilize only 78 cases. In addition to the single male survivor, there was one female patient who reported only rectal penetration and refused examination of the vagina and cervix, as well as the bimanual examination. Therefore, these elements were analyzed for only 77 cases. The researchers acknowledge the development of SANE and SART programs that utilize specially trained nurses for the management of survivors of sexual assault, and who perform evidentiary examinations; provide counseling on pregnancy and STD prophylaxis; act as liaison between the survivor and law enforcement, social service

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personnel, and psychological support systems; as well as provide testimony in a court of law. At their medical center’s ER in Bakersfield, California, a SANE has provided evidentiary examinations of victims of sexual assault since 1995. They write, “These nurses are a valuable resource to ED physicians and nurses, law enforcement, the county prosecutor’s office, and most importantly to the survivor herself. It has been asserted that the SANE has improved the quality of service that EDs are able to provide for survivors of sexual assault, and that they are, in many cases, better expert witnesses than are physicians” (Ledray, 1992a; Ledray & Simmelink, 1997). The researchers explain that in California, SANE training places significant emphasis on the completion of the mandated medicolegal form, and in their study, SANEs demonstrated high compliance levels in the completion of this form; particularly those elements with check boxes or diagrams provided; specifically OB/GYN history, history of the assault, postassault actions, general physical condition, external genitalia examination, cervix and vagina examination, and examination of the anus and rectum had high compliance frequencies. They say that this competence is the result of SANEs training in completion of OCJP 923. However, Minshall and Patel found that several essential elements were poorly documented, despite OCJP 923 written instructions. In particular, section E7 of OCJP 923 states, “Examine the oral cavity for injury and the area around the mouth for seminal fluid. Note frenulum trauma.” The researchers say there is no specific check box or diagram on which the examiner is to record results, and documentation of an examination of the oral cavity was found in only 16.5 percent of cases. The researchers write, “It is unclear whether this lack of documentation is a reflection of this element going unperformed or whether examinations were merely undocumented (perhaps those with no abnormal physical findings), as there is no specific area for documentation. Also, examinations may not have been performed in cases where the survivor did not report any assaultive actions involving the oral cavity.” In addition, documentation of SANEs’ use of the Wood’s Lamp examination was lacking in 35 percent of the cases. Written instructions in OCJP 923 state: “Scan the entire body with a Wood’s Lamp. Label Wood’s lamp findings ‘WL.’” The researchers say poor documentation might simply be due to not having a specific check box or diagram on which to document results, and it is likely that negative findings were not specifically charted. Documentation by SANEs of their performance of the bimanual examination was found in 13 percent of cases, but the researchers note that there is no specific instruction, check box, or diagram provided by OCJP 923 for this element. They add, however, that this element is repeatedly found throughout the medical literature as an essential element in the comprehensive examination of the sexual assault survivor. They state, “The medical literature

Forensic Nursing

supports the bimanual examination as an excellent opportunity to identify injuries which otherwise might have gone undetected, such as vaginal epithelium lacerations and broad ligament injuries.” Notably, a bimanual examination was not part of the routine SANE protocol at the researchers’ facility at the time of their study. Minshall and Patel reported that although the medical literature supports several standard postexamination actions, California’s standard documentation form, OCJP 923, does not provide any instruction or recording area for this information. The researchers noted that SANEs completed these actions “with exceptional frequency.” Specifically, the actions are cultures for STDs, pregnancy testing, STD prophylaxis, and follow-up and referral, which were documented in 98 percent to 100 percent of the medical records the researchers examined. The researchers found, however, that documentation of pregnancy prophylaxis was made in 60 percent of cases, and they acknowledge several influencing factors: three patients were known to be pregnant at the time of the assault, two patients reported no vaginal penetration, and one patient was posthysterectomy. Minshall and Patel say that their state’s mandatory form provides “only minimal consideration for the medical needs of the survivor of sexual assault. Limited space and the omission of medically prudent historical, physical examination, laboratory, and dispositional elements require that an additional recording tool be utilized for comprehensive medical documentation.” They say that documentation beyond OCJP 923 allows the examiner to provide greater detail of the events and circumstances of the assault and would allow the examiner to state direct quotes from the survivor without the constraints of space limited boxes. They conclude: The ED care of its survivors serves multiple purposes and SANEs perform an invaluable service in patient management. The medical literature supports certain documentation standards that may not be equivalent to legal objectives. Medical-legal forms such as this state’s OCJP 923 are convenient but inadequate for comprehensive medical documentation. Additional documentation is required and SANEs must be specifically trained to perform this.

6.6.6.6 In Defense of SANE and SART Programs A number of studies have been conducted that support the efficacy of a SANE program, including a study published in the December 2003 issue of the Journal of Emergency Nursing showing that evidence kits collected by specially trained SANEs provide more effective evidence collection compared with non-SANE-trained nurses and physicians. Crime analysts with the Colorado Bureau of Investigation completed audits on sexual assault evidence kits submitted to the bureau from October 1999 to April 2002. Commercially prepared evidence kits contain swabs, envelopes,

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slides and slide holders, and other tools used to collect and preserve evidence for analysis at a crime lab. Of the kits audited, those completed by SANE nurses were more accurate and complete when compared with those prepared by non-SANE nurses and physicians. Researchers found that evidence kits prepared by SANEs were more likely to have a completed chain of custody (92 percent) compared with non-SANE-collected kits (81 percent). SANEs were also more likely to have properly sealed individual specimen envelopes (91 percent vs. 75 percent), to have labeled the individual specimen envelopes (95 percent vs. 88 percent), and to have included the appropriate number of blood tubes (95 percent vs. 80 percent). Study coauthor Sherry Murphy, a criminal investigator with the Colorado Bureau of Investigation, points to a situation that demonstrated the quality of the work performed by SANEs: DNA analysis of the oral swabs in one specific case resulted in limited interpretation. The anal swabs gave no profile. However, the SANE had also collected swabs from the victim’s chin. That sample was the only one that provided a complete, nonmixture profile of the suspect. The suspect pled guilty upon admission of the test results. This meant that there was not only a conviction, but the victim did not have to testify in court. The defendant in this case was sentenced to 48 years in the Department of Corrections. We have come to expect top quality collection of samples from the SANEs in Colorado and are rarely, if ever, disappointed. (Sievers, Murphy, & Miller, 2003)

Study coauthor Valerie Sievers, MSN, RN, CNS, CEN, SANE-A, a clinical forensic nurse specialist, points out that additional research is needed to document the expertise and value of SANE programs: “Despite the growth of SANE programs in Colorado and across the country, more needs to be done to evaluate the impact of forensic nursing in the areas of health care and criminal justice. It isn’t enough to say that SANE programs make a difference—we need to illustrate that fact in order to secure funding, promote forensic education and ensure a comprehensive health care response to victims of crime and interpersonal violence” (Sievers et al., 2003). “I knew Linda Ledray had conducted a similar study in Minneapolis a number of years before, so I looked at that and kept it in the back of my mind,” Sievers says. But unlike Ledray’s pioneering program, the relatively new SANE program in Colorado had only been in existence for 10 years: In comparison to other programs like Pat Speck’s and Jamie Ferrel’s, it was new so I felt it was important to talk to everyone I could—hospitals, crime labs. I knew it would be helpful if we looked at some sort of baseline, then conduct research to see if we could identify some kind of validation about a different approach to forensic

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nursing—or if not in those terms, show someone having expertise and providing the response to sexual assault patients.

Sievers says the study and the results were welcomed. “For the most part, people in Colorado were very positive about it; they were very excited that we were able to document the efforts of forensic nursing. I think they intrinsically knew what kinds of contributions that nurses were making. And the nurses were happy to know there was additional research to help support what they knew to be true all along. Sievers, whose interest in nursing goes back to when she was a young girl, is among those who have embraced nursing as a rewarding, challenging career. When her mother became ill during her first year of nursing school, Sievers discovered critical-care nursing: Mom spent 10 days in the ICU. I was amazed at the skill and care provided by the ICU nurses. I’ve always been a fan of “the adrenaline rush” that I first felt while working in critical-care areas. After graduating, I worked in intermediate cardiac care and then a surgical-neurological intensive care unit (SNICU). It was a great learning experience. One night while working in the SNICU, an entire family came by ambulance to the emergency department with carbon monoxide poisoning. The night supervisor requested help from the ICU staff to assist with the five code blues. After several hours of working with the trauma team, I knew my next move would be to emergency nursing.

After working several years in the ED and recognizing that victims of violence were not afforded the same response provided to trauma or cardiac patients, Sievers became interested in forensic nursing: On a busy Saturday night, a young mother brought her 7year-old daughter to the ED because she “couldn’t sleep.” When I assessed the child, despite normal vital signs, the hair on the back of my neck stood up. This girl, without any history of illness, was pale, with dark circles under her eyes and tufts of hair missing from her scalp. Over the next few hours, while snacking on graham crackers and being entertained by police officers guarding patients waiting for disposition to the county jail, this little girl told me that her parents were divorced. On the weekends, she stayed with her dad who sometimes worked at night. When her dad was at work, his male roommate would come into her room and “hurt her girl parts.” She said she was having nightmares, was afraid to sleep, and pulled her own hair out. Dad’s roommate had told her she had pretty blonde hair, so she thought if her hair wasn’t pretty, the roommate would leave her alone.

Following a police interview and a less-than-adequate exam by the ED physician, Sievers was convinced that

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adult and child survivors of sexual assault deserved a better response from health care providers. “The next day I contacted the Emergency Nurses Association (ENA) for information on SANE programs. After several years of submitting proposals to the hospital and gaining the support of law enforcement, victim advocacy, and district attorneys, our hospital administrators decided to fund the education and equipment needed to initiate a SANE program.” Sievers is a clinical forensic nurse specialist and statewide SANE coordinator for the Colorado Coalition Against Sexual Assault. Her responsibility is to educate nurses and physicians on appropriate care for victims of sexual assault or abuse and standardized collection of forensic evidence. Tapping into her 16 years of emergency nursing practice, Sievers is part of the SANE team that she developed in 1995 with emergency nursing colleagues. She staffs the local Children’s Advocacy Center several times a month to provide medical-forensic exams for children who require nonacute evaluation and collection of evidence. Sievers’s workdays are filled with variety: On a typical day I may be responding to the hospital to provide care and evidence collection, writing grant reports, reviewing current forensic literature, teaching a class, giving a presentation on forensic nursing and SANE services, working with nurses in other communities to develop a SANE program, or testifying in court. I also provide collaborative strategies for communities interested in SANE programs, present the Colorado-based SANE curriculum to nurses and physicians, and deliver ongoing technical support and education for existing SANE programs. I help inform the public about the SANE program: where to go, what to expect for the patient who has been sexually assaulted, and information on the range of forensic nursing services available to law enforcement, criminal justice, and victim advocacy groups.

“The greatest satisfaction I derive from my work is in knowing that victims of sexual violence are afforded a compassionate and comprehensive response,” Sievers says. “I can stay neutral in this emotionally charged work by realizing that my care of the patient and accurate collection of evidence impacts my responsibility to provide essential courtroom testimony. The understanding of my role as a patient advocate, not a victim advocate, is pivotal in this process.” Sievers says forensic nurses are establishing a new hybrid of heath care delivery: Physicians are medically driven, but they must realize that the practice of the sexual assault nurse examiner is holistic; we are there not to necessarily address all of the patient’s medical needs, but to address the combination of their medico-legal needs with an emphasis on forensic science. There are always those whom I think are uncomfortable or intimidated or realize they don’t have the

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education to necessarily approach these patients and do the kind of job they might otherwise want to do. What we do is so easy to pick apart though; physicians have to realize our documentation is focused on the medical forensic exam.

Sievers says she is fortunate in that the physicians she works with in the ED have understood the role of the SANE: They have always been very supportive but we have a history between us. Long before we started the SANE program officially at Memorial Hospital, I had done probably five years of work with them, providing propaganda, so to speak, on SANE-related issues. I think that even before I started working with the ER doctors, I started working with the prosecutors, the victim advocates, and law enforcement because they were truly the first responders and I felt if I can get them to embrace the idea of having forensic nurses, convincing the physicians would be easier. I mean, I barely got the SANE concepts out of my mouth and law enforcement was all over it. They thought the concept sounded wonderful. Their support really helped to garner support from the ER physicians. Our physician advisor at the hospital has been the director of the ER for 20 years and what she says goes, and she very much embraces the program and is very much a nurse advocate. The ER physicians at Memorial actually use the SANE program as a recruiting tool for new ED doctors. They tell them, “We see a lot of trauma, and one of the things you have to look forward to at our facility is that we have a very diverse nursing staff and a SANE program, so you don’t ever have to worry about testifying in court or providing evidence collection.”

As a young program, Sievers says, Colorado probably avoided a lot of pitfalls encountered by older, more established SANE programs. “I think our program followed the progress of other programs and this was a factor in its early success.” Sievers also credits the program’s success to a number of individuals who helped shape and grow the program: We had the dynamic Jamie Ferrell, who came from Texas to do our education in Colorado Springs, and not only did the nurses love her but hospital administrators did, too. It was helpful being able to say to them, “Here is someone who has done the research and made things happen elsewhere, so we can, too.” Texas had their programs in place for probably 15 years by then; their laws are very close to what we have in Colorado, so that was an easy way to say we can share, shadow, and model what they have done in Texas. We also benefited from the wonderful Dr. Mary Dudley, who is now chief medical examiner for Sedgwick County, Kansas; she’s awesome. When I was starting graduate school at Beth El College of Nursing at the University of Colorado at Colorado Springs, Mary was still teaching there as a clinical nursing instructor. She

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was finishing medical school and ready to go for her residency. She was, and still is, such a great nurse advocate. She was a fabulous support system, and was the person who brought the concept of forensic nursing and a forensic nursing curriculum to Beth El. And Virginia Lynch was one of the inaugural founders of the IAFN. She has authored numerous papers that have defined forensic nursing and roles for forensic nurses, and continues to educate and mentor others. Our program really benefited from the leadership of people who believed in forensic nursing.

Sievers has strong feelings about the need for ongoing education and training opportunities for forensic nurses. She has provided the SANE curriculum in Colorado for the last eight years, and just recently, has had her victim advocacy organization coordinator duties transferred to Beth El: They feel that will be a more supportive and appropriate setting for advanced nursing education. I am excited that there are many available opportunities for nurses, but one of the things I get concerned about is—and I preface this by saying I haven’t had the opportunity to evaluate all the education and all of these models in terms of their credibility and their foundation in nursing practice—is the credibility and quality of SANE training for nurses. I’d like to see some sort of professional organization or nursing education structure be able to accredit those programs. Things are pretty different—even in SANE training—in every state. Their rape kits are different, nurse practice acts are different . . . I get worried about those who get their SANE education on a weekend and think, “I’m really smart, I’ve never done this, but I can develop a curriculum and take it back to my community and use it as a moneymaker.” As opposed to saying, “I am experienced, I am investing in this process, and I am going to take some of my experiential education and pass that on to nurses who need to learn how to approach victims of violence, because I have expertise in forensic nursing.” There are some out there who are diluting the education or are not able to back up what they are saying with credible, professional experience.

Sievers sees changes ahead in emergency nursing: Without some form of universal health care, I think EDs will continue to be overcrowded and utilized by many citizens as a source of primary health care. If this trend continues, more urgent care centers will be developed; emergency departments will be federally regulated and may possibly be designated for the exclusive use of the acutely ill or injured person. ED nurses might also become more specialized; they might focus their area of practice, for instance, on pediatric emergency nursing or geriatric emergency nursing.

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She also believes forensic nursing has made great strides: In 2004 we had our 10th annual IAFN meeting, so we’ve just kind of professionally jelled the concept of forensic nursing over the past decade or so, and I think we have come a long way. There are many great people doing fabulous things. The field has grown and people are realizing that forensic nurses aren’t just nurses who respond to the “knife and gun club” in the ED. Growth will continue but we need to focus on not waiting until nurses have spent 12 years in the ED to realize they are forensic nurses, but incorporating that education at the baccalaureate level and cultivating continued forensic education at the graduate and doctorate levels. We need more nursing professionals who recognize the need to provide expert care to victims of violence. Basic forensic nursing should be included in the curriculum of nursing degree programs. Clinical experience, persistence, and patience go a long way in developing avenues for forensic nursing. Educating our colleagues, hospital administrators, law enforcement, and the public about forensic health care and the impact of forensic nursing can facilitate more career paths.

Other studies point to the characteritics and overall efficacy of SANE and SART programs. Ciancone, Wilson, and Collette (2000) sought to provide a descriptive study of SANE programs and their characteristics in the United States. They mailed a confidential survey addressing patient and staff demographics, administration attributes, examination procedures, and medical and legal issues to SANE programs, and received responses from 61 (66 percent) of 92 programs. They found that 55 percent of the programs had been in operation for less than five years. Thirty (52 percent) of 58 programs performed the initial sexual assault examination in hospital EDs. Written consent (57 of 59, or 97 percent) was obtained for the initial examination, and most (51 of 59, or 86 percent) programs used preprepared commercial sexual assault kits. The researchers found that program directors were predominantly registered nurses. All but one program mandated specific training requirements for their staff, with a median requirement of 80 hours. Procedures used for initial examinations varied; most offered pregnancy testing (56 of 58, or 97 percent), pregnancy prophylaxis (57 of 59, or 97 percent), and STD prophylaxis (53 of 59, or 90 percent). HIV testing was not offered in 32 (54 percent) of 59 programs. Almost all programs used Wood’s lamp (51 of 59, or 86 percent), colposcopes (42 of 59, or 71 percent), and photographs (46 of 59, or 78 percent) for documentation. Median time required per patient for initial examination and evidence collection was three hours (with a range of one to eight hours). Follow-up is consistently offered to the survivor. Most programs (45 of 61, or 74 percent) could report the number of survivors treated, but

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few could provide information on survivor medical follow-up or the number of prosecutions by survivors and their outcomes. Hatmaker, Pinholster, and Saye (2002) report that the community-based Athens-Clarke County SANE (ACCSANE) program was developed to respond to the needs of sexual assault victims. The researchers say that although this type of SANE model allows for a strong nurse-managed program, there are frustrations and pitfalls that differ from most hospital-based programs. At this time, they say, the majority (71 percent) of SANE programs are based in hospitals, and few (15 percent) function in outpatient or community facilities. In the ACC-SANE program, many community agencies interact to provide a seamless approach to postassault health care, counseling, and criminal prosecution. They add that SANEs are well equipped to provide forensic examinations in a caring, out-of-hospital environment. Derhammer, Lucente, Reed, and Young (2000) describe the impetus to the start-up of the SANE interdisciplinary approach to care of sexual assault victims at Lehigh Valley Hospital in Allentown, Pennsylvania in May 1998: “Although many aspects of rape management were in place, a busy ED with varying levels of physician response and exposure to the process of rape management contributed to a lack of standardized, objective, timely, and compassionate medical management of sexual assault victims.” The researchers report that comparing a baseline group of 130 sexual assault victims with 39 patients who were evaluated after the SANE approach was implemented indicated increased clinical interaction and significant improvements in quality indicators, such as completeness of evaluation and information gathered relevant to medicolegal issues. Law enforcement staff developed a more collaborative relationship with SANE examiners through the interdisciplinary team approach. Collaborative relationships were initiated with several other hospitals in the hospital’s integrated delivery system to help offset some of the program’s training, continuing education, and oncall costs and to allow for joint outcomes collection. The SANE program became a core ED service in July 1999. Smith, Homeseth, and Macgregor (1998) report that after several years of planning, the SART at Immanuel St. Joseph’s/Mayo Health Systems in Minnesota became a reality in August 1997. The nurses who were trained for this program were already providing 24-hour coverage in the ED for psychiatric emergencies and patients with chemical dependency; the SANE responsibilities were added to their on-call duties. Five nurses participated in a 40-hour training program led by experts in the local community. Smith et al. write: As expected, nurses were apprehensive as they conducted their first examinations; however, all has gone well. Over time, the providers’ and clients’ satisfaction with the pro-

Forensic Nursing

gram has improved. The examination is completed in less time, and the person assaulted does not have to wait as long for the SANE to arrive. Members of law enforcement and the prosecutor’s office are especially pleased with the quality of evidence collected and the procedures followed to maintain chain of evidence so the evidence obtained can be used in prosecution.

Smith et al. report that the program has resulted in kind and compassionate care for persons who have been sexually assaulted. The providers are continuing to meet monthly as an interdisciplinary, interagency team and are addressing concerns as they arise, and members of the SART are developing a good working relationship. “Everyone involved agrees that developing this program has been a worthwhile effort and that the hospital is providing a valued service for the community.” Ericksen et al. (2002) say that specialized services have been developed to meet the unique needs of survivors of sexual assault, and yet little research has been conducted to investigate clients’ experiences with these services. The researchers conducted an interpretive study to understand the experience of women who were sexually assaulted and then cared for in an emergency setting by professionals associated with a specialized sexual assault service; to discover themes in the experiences of these women; and to discern implications of this experience for delivery of care to women who have been sexually assaulted. They found nine themes emerging from latent content analysis of the interviews, and stated that holistic woman-centered care; the importance of having one caregiver focus on the client’s emotional needs; the importance of touch; and the need for an effective, sensitive, and coordinated response by police and community services were essential components of a health care service provider. Stermac and Stirpe (2002) conducted a study of a SANE program at a hospital-based sexual assault care center in Ontario, Canada, and assess its efficacy in comparison with physician examiners. The researchers obtained data from the hospital records of 515 women who came to a Toronto sexual assault care center. A number of variables relevant to this assessment of services were examined, including client demographics and presenting history, aspects of the sexual assault, and characteristics of the treatment. They found that average assessment times were shorter for victims seen by SANEs than for victims seen by physicians (approximately three hours vs. four hours). Physicians had more interruptions (25.1 percent) than did SANEs (20.0 percent). Greenwood (2003) shared testimonies from community members as to the effectiveness of a SANE program. “The emotional support required by these victims is best rendered by a SANE. This frees the ED nurse to care for other patients, while sexual assault victims receive a high

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level of care,” says Nancy Donel, RN manager at St. Thomas Hospital ED. “The DOVE program benefits not only the emergency physician, but the EMS system as well,” comments Michael Mackan, MD, of the Summa Health System. “It gives us a resource and a specifically identified program with well-trained, qualified providers. Through their training and knowledge, SANEs not only help victims, but also increase the number of legal convictions that take assailants off the streets. This improves the health and safety of the communities in which we live and serve.” Lewis et al. (2003) evaluated the use and effectiveness of a protocol developed for emergency nurses and other medical personnel to use with survivors of sexual assault. The Ohio Department of Health (ODH) Protocol for the Treatment of Adult Sexual Assault Survivors was developed by a multidisciplinary team in 1991–1992 as a written guide to provide comprehensive, standardized, nonjudgmental, and equitable treatment for survivors. In 1993, this 118-page manual was sent to all Ohio hospitals. In 1994, a follow-up video and training guide were also delivered. In 1997, Victims Rights Advocacy, a nonprofit agency in Ohio, and the Center for Social Work Research at The University of Texas at Austin collaboratively conducted an evaluation of the utilization and effectiveness of this protocol at Ohio hospitals. EDs at Ohio hospitals were asked to complete a mailed survey regarding their policies and procedures for treating sexual assault patients. Telephone calls were made to the hospitals that did not return a survey, and site visits were conducted at 20 hospitals in diverse areas of Ohio. Overall, Lewis et al. found that respondents concurred that hospitals can benefit from using a standardized protocol, such as the ODH Protocol, for treating victims of sexual assault. Survey participants also indicated that training is needed on several topics, especially testifying in court, cultural awareness, and the needs of special populations, such as male, gay, lesbian, and bisexual survivors. In addition, findings indicate that survivors need more follow-up services, and written information about these services should be provided to them.

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tim, providers must systematically gather evidence that will document injuries and assist in identifying the assailant, yet must also avoid or reduce further psychological distress and retraumatization of the patient. Discussions with the patient about the assault, gathering and storing of specimens that might eventually link the assailant to the crime, and documentation of injuries must be done in a painstaking, yet respectful way. Evidence must be preserved and stored without contamination or risk of tampering. As a scientist serving law enforcement, the provider might be asked to testify in court about any statements made by the victim and his or her demeanor at the time of the examination, and about the evidence collected. To do an examination correctly and to ensure that the process meets the test of reliability required by a court, a health care provider needs training and experience in what procedures are needed and how they should be done. Many health care providers are not routinely trained or familiarized with the management of victims of sexual assault and other abuse or in the performance of evidentiary examinations. A medical evidentiary examination is given to victims of sexual assault and other forms of abuse and is performed to collect physical evidence and document findings that can be used to identify, prosecute, and convict an assailant. Although an evidentiary examination includes an array of medical components, including assessment of injuries and crisis intervention, its main purpose is to meet the needs of the legal system. It can also be called a medico-legal examination or a sexual assault forensic examination. Basic components of the examination usually include the following: •

•

6.6.7 THE EVIDENTIARY EXAMINATION In a sexual assault case, the victim’s body is the most important source of physical evidence. The victim is, in essence a walking and talking crime scene. A medical evidentiary examination is an examination done by a health professional that includes attention to the medical needs of the victim as well as to the gathering of evidence for law enforcement purposes. It typically includes medical evaluation and crisis intervention, forensic evidence collection, evaluation of emotional needs, and referral for follow-up care. A medical evidentiary examination can be a key element in the successful prosecution of sexual assault and other violent crimes. When examining a vic-

•

•

Medical evaluation and crisis intervention: Recognition and treatment of physical injuries, risk evaluation and counseling for STDs and pregnancy. Forensic evidence collection: Evaluation, collection, and preservation of evidence; interpretation of findings; and the documentation of examination results for law enforcement purposes. Evaluation of emotional needs: Assessment of psychological functioning, response to the immediate emotional needs of the victim, and referral for appropriate follow-up mental health evaluation and treatment. Referral for follow-up care: Assessment of the need for follow-up treatment and services, with written instructions for the patient on recommendations for further treatment of injuries, laboratory testing, and mental health services, and the names and phone numbers of referral organizations.

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The examination should be based on an integrated clinical approach that considers and responds to cultural issues for victims of diverse racial, ethnic, and economic backgrounds. Culturally congruent care includes sensitivity to victims who might be intimidated by police, such as an immigrant or homeless person; to victims who need translation services; or to women who cannot admit being violated without being ostracized from family and community. The way the examination is conducted is affected by factors such as the clinical protocols used in a particular health care institution, the type and contents of the rape kit used by the hospital, the length of time elapsed since the attack (which affects the viability of some types of evidence), whether police believe that drugs might have been used in the attack, the nature of the attack, and whether the victim has bathed or changed clothes. Examination of vulnerable populations such as the disabled, the elderly, or young children, presents special challenges to the examination process that the forensic nurses must be equipped to handle.

6.6.8 TRAINING

OF

HEALTH CARE PROVIDERS

To perform an evidentiary examination correctly and to ensure that the process meets the test of reliability that a court will one day demand, a health care provider needs training and experience in what procedures are needed and how they should be done. Voelker (1996) and Stobo, Salmon, and Cohn (2002) assert that most health care providers are not routinely trained or familiarized with the management of sexual assault victims and the performance of evidentiary examinations. The training model that is growing rapidly and bringing substantial change to the field, of course, is the aforementioned SANE/SART programs; however, other models exist. Other organizations that offer continuing education (CE) programs to develop the skills needed to perform medical evidentiary examinations include a handful of state-funded programs, such as the California Medical Training Center at the University of California-Davis that provides specialized multidisciplinary training and distance learning facilities, and the Texas Office of the Attorney General, which provides financial support and technical assistance for development of SANE/SART training programs throughout Texas, and has a full-time unit to encourage these programs. Several professional organizations have developed materials, policies, and course offerings related to sexual assault, including the American College of Obstetricians and Gynecologists (ACOG). The ACEP has developed a detailed examination protocol, as well as other materials and training. Distinct from educational programs that are offered at a particular time and place and are part of a formal training process, guidelines, professional standards, and clinical practice protocols are developed by professional organi-

zations or quality improvement bodies to help guide practicing providers toward improved health outcomes. In recent years, the development of guidelines and protocols has grown, as evidence-based medicine has become a dominant force in the way medicine is practiced. A number of specialty-specific professional organizations and accrediting bodies have developed clinical protocols, training materials, professional standards, and policy statements to assist their members in practice. These organizations include the JCAHO; the American Academy of Pediatrics (AAP), ACEP, ACOG, the AMA, the American Professional Society on the Abuse of Children (APSAC), the American Academy of Child and Adolescent Psychiatry (AACAP), the American Society for Testing and Materials (ASTM), and the CDC. Training is discussed in greater detail in chapter 15.

6.7 THE COST OF SEXUAL ASSAULT Essential to any study of forensic nursing programs is the cost of abuse and assault to society. The most recent study to assess both immediate and long-term costs of sexual assault was published by the National Institute of Justice (NIJ) at the Department of Justice in 1996. The report indicated that costs associated with nonfatal rape and sexual assault averaged $87,000 per incident for adults, and $99,000 per incident for children. The estimates consider both immediate use of medical care and mental health services, lost productivity, and permanent disability, as well as the cost of less tangible impacts such as pain, suffering, fear, and lost quality of life. The researchers estimated that between 10 and 20 percent of mental health care expenditures in the United States might be attributable to crime victims who seek treatment as a result of their victimization. The total costs per incident of nonfatal rape and sexual assault are estimated at $87,000, including $2,200 in productivity losses, $500 for medical care expenses, $2,200 for mental health care, and $81,400 associated with reduced quality of life. The average total cost per incident of child abuse is $60,000, including $2,200 in lost productivity, $430 in medical care costs, $2,500 for mental health care, and $52,371 in reduced quality of life. The greatest losses are associated with sexual abuse ($99,000 per incident), followed by physical abuse ($67,000) and emotional abuse ($27,000). These figures were derived from the analysis of 1,106 jury awards and settlements to assault, rape, and burn survivors to compensate for pain, suffering, and lost quality of life (excluding punitive damages). The total annual losses in the United States associated with child abuse (including sexual, physical, and emotional abuse) are estimated at $56 billion, including $23 billion specifically for rape and sexual assault. Total annual losses associated with rape and sexual assault of adults are estimated at $127 billion, including $4 billion

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in medical costs, $3.5 billion in other tangible costs, and $119 billion in quality of life. Total annual losses associated specifically with adult domestic violence (including fatalities, rape, other assaults and robbery) are estimated at $67 billion, including $1.8 billion for medical care, $7 billion for other tangible costs, and $58 billion for quality of life. Injuries of sexual assault victims ranged from minor to moderate, according to results of the 1995–96 National Violence Against Women Survey (NVAWS), a telephone sample survey that collected information on medical services provided to adult victims of rape. The survey established that: •

•

•

About one third (31 percent) of female rape victims reported physical injuries. Almost three quarters of the injuries (73 percent) were minor (e.g., scratches, bruises, or welts). About one third (36 percent) of those injured received some type of medical care. The majority of injured female victims who received care were treated in a hospital (82 percent). Although most of those treated in a hospital were seen in the ER or an outpatient department, about 13 percent stayed for at least one night, with an average stay of 3.6 nights for those admitted on an inpatient basis. About half (55 percent) of all women who received medical care were treated by a physician outside of a hospital and averaged 4.8 office visits related to the injury. Somewhat less than one fifth received dental care (16.9 percent). A similar proportion visited a physical therapist (16.7 percent).

6.8 QUALITY-OF-CARE ISSUES A number of quality-of-care issues relating to variations in SANE/SART practice have been raised by the nurses who provide this care, as well as the agencies and institutions that depend on their services. These issues include lack of standardized protocols, procedures, and rape testing kits in use; lack of trained providers and expert consultants; uneven quality of examination facilities and technologies available; and poor quality and limited capability to test for drugs and DNA. What little data exists suggests wide variations in access to and quality of services received by victims of sexual assault, including length of waiting times; provision of information or testing for STDs; the availability of nurse examiners or other providers with specialized expertise in evidentiary examinations; the presence of extraneous personnel during the examination; the availability or referral to other community resources such as advocacy organizations or social service

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agencies; and the availability of private waiting areas, examination rooms, showers, or the provision of clothing. Access to medical evidentiary examinations is not uniform across the United States and access can be compromised by payment issues. Although numerous federal and state laws have been enacted to ensure that victims of sexual assault do not have to pay for medical evidentiary examinations, some states limit payment to victims who indicate a willingness to report the assault, a decision the victim might not want or be able to make immediately. Even when the victim is willing to commit to formally filing a report and cooperating with prosecution, the law enforcement agency or prosecutor still might not be willing to approve payment for an examination if they feel the case is weak, a decision that is made in the early stages of an investigation. In addition, it is the opinion of many experts working in the field that despite legal prohibitions, billing of the patient victim continues to be widespread.

6.8.1 MANDATORY REPORTING At the state level, mandatory reporting seems to be one of the most important contributions that government is making toward addressing sexual assault and abuse issues. Almost all states have mandatory reporting requirements for child abuse and elder abuse, and three fifths have or are developing practice protocols on sexual assault; 45 states have or are developing standardized evidence collection kits. A few states have established mandatory educational requirements for health professionals, and about half of the states have SART/SANE programs. Mandatory reporting laws require physicians, and often nurses, other health professionals, and clergy, to report actual or suspected sexual assault and other types of abuse and neglect. In 48 states, health care professionals are required to report known or suspected instances of actual or suspected child abuse, and most states also require physicians to report if they believe that elder abuse has occurred. According to Stobo et al. (2002), four states (California, Colorado, Rhode Island, and Kentucky) specifically require physicians to report intimate partner abuse, even if the victim’s wishes are otherwise. Houry, Sachs, Feldhaus, and Linden (2002) say that 42 states require health care providers to report injuries resulting from firearms, knives, and other weapons. Opposition to mandatory reporting laws has occurred, and reasons include the following: • •

•

Mandatory reporting might expose a victim to retaliation, as many know their assailant. A lack of informed consent around the reporting issue compromises the patient–provider relationship. It takes away the autonomy of sexual assault victims for whom a sense of regained control

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over their life can be an important step to recovery. There might also be a discrepancy between the legal requirements and the health care provider’s personal threshold of what they feel constitutes abuse.

6.8.2 ADDRESSING THE ISSUES OF QUALITY OF CARE The Institute of Medicine (IOM) report, Confronting Chronic Neglect (National Academy Press, 2002) identified a number of practice variations with which forensic nurses across the country are grappling. 1. Lack of standardized protocols, procedures, and rape kits. A number of protocols and procedures have been developed, but there is considerable overlap. More important, there are significant differences among the protocols in use and none have been compared or rigorously assessed, at least until now. The national sexual assault protocol, issued in September 2004 by the U.S. Department of Justice, is examined at the end of this chapter. 2. Lack of trained providers and expert consultants. Voelker (1996) asserts that although there are curricula for instructing how to perform a medical evidentiary examination, these programs have reached only a few, self-selected providers. There have been notable efforts to extend and support forensic training programs to health professionals already in practice, but the sheer number and types of providers who might see a sexual assault victim is daunting. The IOM report makes the point that all providers need basic competencies. 3. Uneven quality of examination facilities and technologies available. Most victims who seek medical care, although not all, are examined in a hospital setting. Many hospitals have developed special areas and separate facilities for examining patients, to provide a place where the lengthy examination will not impede care for other types of patients coming into an ER, to make available the special equipment and storage facilities used in such examinations, and to provide the victim a sanctuary that protects her or him from further traumatic experiences. Quiet, age-appropriate environments are thought to be especially important when examining children, who are particularly vulnerable to retraumatization and who also need examiners who are trained to meet the specialized needs of child victims. Specialized and separate sexual assault units within or near a hospital are viewed by many as ideal from a patient’s per-

spective, but such facilities are not available in all hospitals. Reasons include lack of space; too few patients to make it an effective use of reserved space; an unwillingness or inability to spend the resources needed to establish and maintain a dedicated sexual assault unit; and a lack of understanding by administrators or the community about the importance of specialized care. Equipment and space are expensive resources, and smaller, rural hospitals might have particular difficulty creating a viable program, facility, and trained staff. 4. Limited capability to test for drugs and DNA. Most hospitals do not routinely test for the full range of drugs (including substances used in drug-facilitated rape). Even fewer have the skills and technology to handle DNA testing, which has assumed additional importance with the advent of state DNA banks. DNA evidence can easily be compromised by untrained providers who are involved in the collection and preservation process. The sample can be contaminated if someone sneezes or coughs over the evidence, or even if the examiner touches his or her own hair or body and then touches the area to be tested. According to Turman (2001), it is also affected by heat and humidity, and is easily degraded. Forensic DNA testing is a lengthy and expensive process, but one which is often paid for by law enforcement or the prosecutor’s office. However, even police labs often lack adequate forensic testing capabilities. In partial response to these issues, a federal law, the Paul Coverdell National Forensic Sciences Improvement Act, was enacted in 2000, authorizing approximately $500 million in federal funds over a five-year period to be used by states to improve procedures for testing DNA samples, hire and train personnel, modernize laboratory equipment, and improve the quality and timeliness of forensic science services. The Justice for All Act of 2004 is another example of a federal attempt to increase capacity and resources to handle biological evidence; this piece of legislation is examined in chapter 14. 5. Challenged access to services. Reports endeavoring to characterize the type and quality of victims’ services indicate sweeping variations. One survey found that 55 percent of rape victims had not been given information on HIV testing and that one third were not given information about other STD testing. The practice of immediate testing for STDs is controversial because any infection found would reflect prior exposure, and not all assaults will expose a

Sexual Assault

patient to STD risks. However, others favor it as baseline information, and virtually all experts agree that the provider should stress the need for follow-up STD evaluation and treatment for patients at risk, according to the CDC (2002). Maxwell and Soubielle (1996) surveyed 130 Florida hospitals; of the 64 facilities that responded (49 percent): • 88 percent saw rape victims through the ER. • Six hospitals reported that law enforcement personnel assist in the exam, a violation of the state’s evidence collection protocol. (Most experts in the field agree that, except in rare cases, there is no medical or legal reason for law enforcement representatives, male or female, to be present during the exam. Maintaining the chain of custody during the examination is a function and responsibility of the attending medical personnel and one that should not require outside assistance.) • Although the JCAHO calls for ongoing inservice training, only about one fourth of hospitals reported that they provided such training for the personnel conducting examinations. • Most hospitals only involve local rape crisis center personnel if requested to do so by the victims, many of whom do not know that such services exist. • Fewer than half of the hospitals reported that they provide written material on common rape reactions and community resources as a usual practice; 15 percent said they do not provide the victim with any information on resources. • Just over half of the hospitals set aside separate rooms for rape victims and some provide showers for the rape victims after the exam, maintain a clothing closet, or provide underwear or paper jumpsuits to patients whose clothing was collected. • Most hospitals (82 percent) discussed HIV screening with patients and dispensed prophylactic drugs for STDs (88 percent). 6. Access issues involving payment for evidentiary exams. When a sexual assault victim presents to a hospital or clinic, medical staff will typically assess and respond to serious or lifethreatening injuries. However, the decision to do a formal evidentiary examination is dependent on the patient, who must give written consent, and is affected both by state laws and the judgment of local law enforcement officials or prosecutors as to whether an examination will be useful and can be justified.

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Numerous federal and state laws have been enacted to ensure that victims of sexual assault do not have to pay for medical evidentiary examinations. However, some states limit payment only to victims who are willing to report the assault to police and to cooperate in any prosecution. If the assault is not reported, or the case is not prosecuted, the victim might be unable to obtain a full examination, or might have to pay for the costs of an examination. A number of states place responsibility for payment on the county where the sexual offense occurred, or on the entity that requests the examination, most often the investigating law enforcement agency or the prosecuting attorney. If the county official, police officer, or prosecutor is told that the victim does not plan to formally report the assault (a decision that the victim might not want or be able to make immediately, and a decision that sometimes changes), they might not approve payment for an examination. Similarly, if they believe that the victim’s account is weak or that successful prosecution is unlikely, they might act to preserve limited resources and not provide approval for payment. Even when state laws mandate that victims not be charged for the expense of evidentiary exams, there are cases in which claims might be submitted to third-party insurance companies, compromising the victim’s privacy, as insurance companies might not only be informed of the sexual assault but could also learn about exposure to HIV or other aspects of treatment that could affect insurance coverage in the future. Victims might also be forced to disclose the assault to the primary person on the insurance, such as a family member or even an employer. Victims of crime are not generally required to cover the costs of evidence collection incurred in the investigation of their cases. Despite the fact that most states have laws that designate payment sources to cover the costs of forensic exams for sexual assault victims, and some even specifically prohibit billing of victims, billing of sexual assault victims continues to be widespread, according to 2003 data from the National Center for Victims of Crisis.

6.8.3 EVIDENCE

OF

SANE/SART EFFICACY

Ledray (2001) says that little research data is available on the efficacy of the SANE/SART model, with the bulk of the information contained in anecdotal case studies. For the nurse working as a SANE, much validity comes through a job well done; benchmarking and best practices will have to catch up with real-world performance. Until then, it has been documented by Frank (1996) that without a SANE in the ED, victims encounter rushed, overworked health care providers who might appear aloof and insensitive. The SANE is able to provide not only the evidentiary exam, but also additional resources and support that facilitate follow- through in the judicial process. (Frank, 1996;

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Ledray, 1992a, 1992b) Arndt (1988) found that this assistance can trigger an increase in reporting by victims. Ledray (1999) discovered that in one program, 38 percent of 337 rape survivors were uncertain about reporting when they first came to the hospital ED. After meeting with a SANE, an additional 12 percent opted to report, and the police were called to the ED. An additional 23 percent agreed to have an evidentiary exam completed because they thought they would report. Only 3 percent of the 337 survivors in this study did not report. Speck (1995) asserts that a SANE program satisfies a victim’s physical and emotional needs because it dramatically reduces a victim’s waiting time in the ED. Speck reports that in a client satisfaction questionnaire mailed to 201 survivors two weeks after they were seen by a SANE for an exam, 93 percent of those returning the questionnaire were satisfied with the care they received. SANEs also perform more efficient and accurate forensic evidence collection, the result of thorough training and competent experience on the job. Ledray (2001) notes, “A primary advantage of the SANE program is that with a limited number of dedicated nurses completing all of the evidentiary exams in a given hospital or regional area, they are able to complete an adequate number of exams to develop and maintain this proficiency.” Additionally, SANEs have worked with prosecutors and law enforcement personnel to develop a better understanding of the medical competencies required to obtain forensic evidence that helps obtain convictions. Researchers have found that SANEs also provide more thorough documentation. Ledray and Simmelink (1997) compared 24 sexual assault evidence kits collected by SANEs to 73 evidence kits collected by non-SANEs; the SANE kits were overall better documented, more complete, and always maintained proper chain of evidence, whereas the others did not. Thirteen kits completed by non-SANEs either had no indication of who had collected the evidence or it was illegible, making the evidence useless. All of the SANE kits were properly labeled. In addition, the work of SANEs has been found to improve prosecutorial outcomes. Although there are reports of attorneys who were initially concerned about the testimony of SANEs, Ledray (2001) says they later admitted that SANEs were extremely credible witnesses in court due to their extensive experience and expertise in conducting the evidentiary exam. Yorker (1996) states that prosecutors trust the competence of the SANE as a witness if the case goes to trial, and Lenehan (1991) reports that SANEs have the credential needed to validate their work. It is essential that health care providers, in the course of performing their duties, are objective and as free as possible from any prejudice or bias. It is possible to provide an objective service without sacrificing sensitivity or compassion. The need for impartiality is especially impor-

Forensic Nursing

tant when providing evidence—in the form of a written report or court testimony—in cases that proceed to criminal prosecution. Investigators, consciously or unconsciously, can bring considerable pressure to bear on health care practitioners to provide an interpretation that would resolve an issue. These forces could be direct and forceful, or subtle and insidious, and are likely to be particularly strong in situations where the practitioner has a formal relationship with an investigating authority, where a close personal relationship has developed between the investigator and the practitioner, or when the individual roles of the investigator and the practitioner become blurred. Fairness might also be compromised when the practitioner develops an unconscious or misplaced desire to help investigators. In The Effectiveness of Sexual Assault Nurse Examiner (SANE) Programs, author Rebecca Campbell, PhD (2004), associate professor of community psychology and program evaluation at Michigan State University, affirms what forensic nurses have always known: They provide high-quality, effective, medico-legally sound service to victims in forensic cases. She writes, “The role of SANE nurses is complex, as they must attend to the medical, forensic, and psychological needs of their patients” (Antognoli-Toland, 1985; Littel, 2001; Taylor, 2002), adding that they minimize the victim’s physical and psychological trauma and maximize the probability of collection and preservation of evidence for potential use in the legal system (Young et al., 1992). Campbell adds, “Although it is often the forensic aspects of SANE nurses’ work that receive the most attention by the legal and medical communities, Ledray, Faugno, and Speck (2001) emphasize this psychological care dimension when they noted that a SANE nurse is a compassionate and supportive nurse who is also a skilled forensic technician.” Campbell points to a few studies that have systematically evaluated the psychological impact of SANE programs. In a study of the Memphis SANE program, Solola, Scott, Severs, and Howell (1983) found that 50 percent of victims in their study sample were able to return to their usual vocation within one month, and in three to six months, 85 percent felt secure alone in public areas. At the end of a year, more than 90 percent of the survivors were entirely free of their initial assault-related anxieties and emotional discomposure. Other research, Campbell says, suggests that at the very least, rape survivors perceive SANE nurses as helpful and supportive. Malloy (1991) surveyed 70 patients in crisis, and found that 85 percent of the survivors identified the nurses’ listening skills as a mechanism that helped them the most during their crisis period. Ericksen et al. (2002) conducted semistructured qualitative interviews with eight survivors who were treated in a Canadian specialized sexual assault service that included specially trained physicians and SANEs. The researchers identified several common

Sexual Assault

threads in the participants’ narratives: Victims felt as though they were respected as a whole person, their needs were met and they were treated with dignity and respect, they felt the presence of the nursing staff provided information about what to expect, they felt safe among female caregivers who were sensitive, they felt in control because they were given options and were not pushed toward certain choices, they felt reassured and believed by the staff, they felt they were cared for by people with expertise, and they felt cared for beyond the hospital setting because they received follow-up care or the option for follow-up care. Campbell reports that “empirical studies that directly compare the evidence collected by SANE nurses and physicians on objective criteria would better inform the debate over whether nurses are competent medical forensic examiners.” She points to two such studies conducted in the United States. Ledray and Simmelink (1997) reported the findings from an audit study of rape kits sent to the Minnesota Bureau of Criminal Apprehension. Twenty-seven kits conducted by SANE nurses were compared to 73 kits collected by physicians or non-SANE nurses with respect to completeness of specimens collected, documentation, and maintenance of chain of custody. Overall, the SANEcollected kits were more thorough and had fewer errors than the non-SANE kits. For example, with respect to completeness of evidence, 96 percent of the SANE kits versus 85 percent of non-SANE kits collected the swabs to match the recorded orifice of penetration, 92 percent of the SANE kits versus 15 percent of non-SANE kits contained an extra tube of blood for alcohol and drug analysis, and in 100 percent of the SANE kits versus 81 percent of non-SANE kits, a blood stain card was properly prepared. In addition, the chain of evidence was broken in nonSANE kits but was always maintained in SANE kits. “Although these descriptive data suggest that the SANE nurses’ evidence collection was more thorough and accurate, inferential statistics were not reported so it is not known whether these differences were statistically significant,” Campbell says. A larger scale, Colorado-based study by Sievers et al. (2003) explicitly tested differences between SANE and non-SANE kits, and also found support for better evidence collection by SANE nurses. Specifically, this study compared 279 kits collected by SANE nurses and 236 by doctors or non-SANE nurses on 10 quality control criteria, and found that in nine of these 10 categories, the SANE-collected kits were significantly better. The kits collected by SANE nurses were significantly more likely than kits collected by physicians to include the proper sealing and labeling of specimen envelopes, the correct number of swabs and other evidence (pubic hairs and head hairs), the correct kind of blood tubes, a vaginal motility slide, and a completed crime lab form. Sievers et al. (2003) provide the strongest evidence to date that SANE nurses are qualified to conduct forensic exams, and in fact, they perform them

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better than physicians. However, it is important to note that training and experience, not job title or professional degree, are the likely reasons behind these findings. Further underscoring the link between experience and evidence quality, DiNitto et al. (1986) reported that prosecutors in Florida were “satisfied with evidence collected by nurse examiners, crediting the training of the nurse examiners . . . Prosecutors tended to be more pleased with the quality of a physician’s evidence when the examiner had conducted many exams and thus had perfected the techniques.” Because SANE nurses have made it a professional priority to obtain extensive forensic training and practice, it is not surprising that both case study and empirical data suggest they are better medical forensic examiners than physicians and nurses who have not completed such training. SANEs provide law enforcement personnel and prosecutors with detailed forensic evidence documenting crimes of sexual assault, which raises the question of whether SANE programs have an impact on prosecution rates in their communities. The literature suggests that SANE programs increase prosecution, according to Aiken and Speck (1995), Cornell (1998), Hutson (2002), Littel (2001), and Seneski (1992). For example, there are reports that SANE programs specifically increase the rate of plea bargains because when confronted with the detailed forensic evidence collected by the SANE nurses, assailants decide to plead guilty (often to a lesser charge) rather than face trial, according to research by Aiken and Speck (1995), Ledray (1992a, 1992b), Littel (2001), and Seneski (1992). Other research indicates that when cases do go to trial, the expert witness testimony provided by SANE nurses is instrumental in obtaining convictions, according to O’Brien (1996), Smith (1996), and Ledray (1999). Yet there have been few studies that have empirically tested the hypothesis that SANE programs increase prosecution. Studies that report the prosecution rates for SANE programs rarely include a comparison group (e.g., rates before and after the SANE program was implemented, or comparisons to another community without a SANE program). However, there is already an extensive literature on what are considered to be typical rates of prosecution in communities without SANE programs. For example, arrest rates in rape cases have been found to vary between 25 percent (Frazier & Haney, 1996) and 49 percent (Spohn & Horney, 1992). Prosecution rates are substantially lower, with only 14 percent (LaFree, 1980) to 35 percent of reported cases successfully prosecuted. Only 7 percent (Galvin & Polk, 1982) to 17 percent of cases end with a guilty verdict or guilty plea bargain. Solola et al. (1983) examined the legal outcomes for 621 victims who were treated in the Memphis SANE program in 1980. Police reports were filed in 573 of these cases (92 percent), and 124 resulted in an arrest and successful prosecution (22 percent of reported cases). However, 135 cases were still pending at the time this study

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was conducted, and if the rates of arrest and prosecution are examined only in closed cases, the prosecution rate was 28 percent. In either analysis, the prosecution rate of 22 percent or 28 percent is still low, but higher rates that have been found for non-SANE cases. In a study of the Santa Cruz County SANE program, Arndt (1988) noted that 42 percent of sexual assaults involving victims 14 years and older resulted in arrests of the perpetrators, and 58 percent of child molestation cases resulted in arrest. Ledray (1992a, 1992b) reported that of 417 rape cases in Minneapolis in 1990, police presented 193 cases to the county attorney (46 percent); of those 193 cases, 60 were not charged by the prosecutor (31 percent), 65 defendants pleaded guilty (34 percent), and 14 went to trial (7 percent). Six perpetrators were found guilty and eight were found not guilty (the outcomes in the remaining 54 cases were not reported). The rates of guilty plea-bargaining reported in this study are higher than those found in studies of non-SANE jurisdictions, researchers conclude. Ledray notes that a stronger methodological design would include a direct comparison of legal outcomes for SANE cases versus non-SANE cases, and points to work by Crandall and Helitzer (2003). They compared the legal outcomes for sexual assault cases seen at the University of New Mexico’s Health Sciences Center for the two years prior to the inception of a SANE program (1994–1996, n = 242) and four years afterward (1996–1999, n = 715). A significantly higher percentage of victims treated in the SANE program reported the assault to the police than did before the SANE program was launched in this community (72 percent vs. 50 percent) and significantly more survivors had evidence collected using approved kits (88 percent vs. 30 percent). Police filed more charges of sexual assault post-SANE as compared to pre-SANE (7 charges per perpetrator versus 5.4). The conviction rate for charged SANE cases was also higher (69 percent vs. 57 percent), resulting in longer average sentences (5.1 vs. 1.2 years). These data provide the strongest evidence yet that SANE programs can have a beneficial impact on the prosecution of sexual assault cases, according to Ledray.

6.8.4 HEALTH CARE PROVISION OF SEXUAL VIOLENCE

FOR

VICTIMS

According to the WHO (2003), there are a number of givens regarding the delivery of health care to victims of sexual violence: • •

•

The health and welfare of the patient is the foremost priority. Ideally, the health care and medico-legal services should be provided at the same time and in the same place by the same person. Health care professionals should receive special training in providing services for victims of sex-

•

•

•

ual violence and should also have a good understanding of local protocols, rules, and laws applicable to the field of sexual violence. There should be a constructive and professional relationship with the other individuals and groups treating and assisting the victim or investigating the crime, as networking with other service providers can help ensure comprehensive care. Health care professionals should be free of bias or prejudices and maintain high ethical standards in the provision of services. Resource constraints might preclude the possibility of service provision in an ideal facility, but it is possible to improve the quality of existing facilities by ensuring they are accessible, secure, clean, and private.

Kilpatrick (1992) says that even though many sexual assault survivors do not sustain serious physical injury as a result of the assault, they still access the medical system for STD treatment, HIV/AIDS testing, emergency contraception, forensic evidence collection, and medical care. Sexual assault also has health effects that extend beyond immediate medical and forensic needs. Kimerling and Calhoun (1994) found that rape victims seeking care at a rape crisis center had more self-reported physician visits than nonvictims up to one year after the sexual assault. There have been many long-lasting symptoms and illnesses that have been associated with sexual victimization including gastrointestinal disorders and a variety of chronic pain disorders including pelvic, back, and facial pain and headaches. Given the fact that health care facilities are a common point of entry for sexual assault survivors, the medical system is in a unique position to identify survivors of sexual assault and to refer them to counseling and advocacy services. Research has shown that the response by health care professionals can either increase or diminish survivors’ psychological consequences of sexual assault (Cohen, Donohue, & Kovener, 1996). As initial responders in many sexual assault cases, the medical system plays an important role in survivors’ recovery. The important role that health care providers play in the lives of sexual assault victims was underscored in The Response to Sexual Assault: Removing Barriers to Services and Justice, a report of the Michigan Sexual Assault Systems Response Task Force (2001). This workgroup’s goal was to provide health care professionals with guidelines and best practices for responding to the medical needs of victims of sexual assault. The task force identified the following issues and made the following recommendations: Issue 1: Coordination of Supporting Disciplines. Burgess, Fawcett, Hazelwood, and Grant (1995) assert that dealing

Sexual Assault

with sexual victimization requires the collaborative and cooperative efforts of a network of services, but many individuals are not informed of services available to them. Recommendations: Where a sexual assault program advocate is available, the ED and sexual assault program should work together to enhance the provision of immediate care and support for survivors. Law enforcement is also a resource for survivors of sexual assault. Hospital staff, physicians, health department nurses, alcohol and drug treatment counselors, dentists, health educators, prenatal health care providers, HIV/AIDS counselors, psychologists, social workers, family planning specialists, and mental health providers should be aware of the services available for sexual assault survivors in their community and make appropriate referrals. The medical system should participate in or initiate the community development of a victim-centered coordinated community plan to respond to sexual assault to better serve the immediate and long-term needs of sexual assault survivors. Further, “Well-planned multidisciplinary community response plans have been demonstrated to be cost effective while diminishing further harm to the (sexual assault) patient and providing comprehensive care” (ACEP, 1999). The medical system should be included in SARTs. Regardless of where the survivor enters the system—a police station, an ED, or , phone call to a sexual assault program’s crisis line—the SART can be activated. A SART has the potential to provide a greater continuum of care for sexual assault survivors, increased quality of care for survivors, and a reduction of the secondary trauma that survivors often experience as they move through the medical, judicial, and law enforcement systems. SART programs can also increase the investment in providing a better response to survivors of sexual assault by all team members and keep the focus of the response on the survivor. If survivors of sexual assault experience a more compassionate and collaborative response, they might be likely to make a police report and participate in prosecution. The ED directors should promote within the department a cooperative and professional working relationship with, and understanding and respect for, the role and responsibilities of the local sexual assault service programs, the prosecuting attorneys, and law enforcement. Issue 2: Mandatory Reporting of Sexual Assaults by Medical Personnel. Many health care providers are confused by their state’s mandatory reporting law. Recommendations: Facilities should discuss and provide guidance on the implications of mandatory reporting due to the complexity of issues involved. The discussion should include careful consideration of the patient’s right to privacy. Input should be sought from individuals representing law enforcement, prosecutors, sexual assault programs, and health care professionals.

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Issue 3: Training. There is minimal training in medical and nursing schools on meeting the medical and emotional needs of sexual assault survivors as well as on conducting forensic evidence collection. Cohen et al. (1996) found that 56 percent of physicians and 63 percent of nurses indicated that they received no forensic training. Health care providers reported that the first time they became familiar with the forensic evidence collection kit was when they were forced to complete one. Lack of training often results in inconsistency of care, incorrect or incomplete forensic examinations, and inappropriate documentation. All medical professionals who currently conduct sexual assault evidence collection need specialized training. All trauma responders should possess the same level of competence in responding to sexual assault that they have in responding to other types of trauma. The goal is to improve the health care response to sexual assault survivors through ensuring that all health care professionals have a basic understanding of the dynamics of sexual assault and how to appropriately respond to survivors. Recommendations: All health care facilities that provide treatment to sexual assault survivors should follow the recommendations outlined in Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient (ACEP, 1999). Health care professionals who provide medical care and collect forensic evidence should demonstrate competence in the following areas: multidisciplinary team concept; dynamics of sexual assault; sexual assault forensic examination; proper handling of evidence (maintaining chain-of-evidence); anatomy and physiology as it relates to sexual assault; psychological aspects of sexual assault; the role of the forensic examiner in the criminal justice system; medical management of STIs, HIV, and pregnancy; and services available to survivors. Health care facilities should provide training on these topics. Trainers can include the local sexual assault program, the prosecutor’s office, law enforcement agencies, forensic nurses, the local health department, and other local and national experts in the care of sexual assault survivors. Training should be provided to health care professionals on effective, culturally competent communication with victims including the use of interpreter services and assistive technology. Training for health care professionals should also address how to appropriately document cases of sexual assault. Documentation should be based in fact, use quotes whenever possible, and make no judgmental statements. This training should include prosecuting attorneys. Health care facilities should comply with the JCAHO guidelines requiring emergency and ambulatory care facilities to have protocols on rape, sexual molestation, and domestic violence. To meet these guidelines, health care providers must develop services that identify and document cases of sexual assault and refer victims to agencies that can provide further support and advocacy. According to the JCAHO guidelines, appropriate management of the patient

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requires a standardized clinical evaluation as well as effective interface with law enforcement for the handling of forensic evidence and coordination of the continuum of care with a community plan. It also requires health care providers to address the medical and emotional needs of the patient while addressing the forensic requirements of the criminal justice system. Medical issues include acute injuries and evaluation of potential STDs and pregnancy. Emotional needs include acute and nonacute crisis intervention and referral for appropriate follow-up counseling, support, and advocacy. Forensic tasks include thorough documentation of pertinent historical and physical findings, proper specimen collection and handling of evidence, and presentation of findings and conclusions in court. Health care professionals should also receive training on evidence collection techniques with suspects. It is useful in police investigations to collect forensic evidence from the suspect as well as the survivor. Issue 4: FNE Program Development. Current treatment of sexual assault survivors in traditional ED settings often revictimizes survivors seeking care. Because the vast majority of sexual assault survivors do not sustain serious physical injuries, they can often be forced to wait, sometimes up to 12 hours, while not being allowed to urinate, drink, shower, or change clothes to preserve physical evidence (Thomas & Zachritz, 1993). In seeking ways to treat and collect evidence from sexual assault survivors with more sensitivity and effectiveness, and to ensure empowerment rather than revictimization, some communities have established FNE programs (Lang, 1999). Although most FNE programs started by conducting forensic and medical exams with sexual assault survivors, these programs have increasingly been used to conduct forensic exams (document, collect evidence, and treat injury and trauma) with domestic violence survivors. Because of the common application in sexual assault cases, many nurse examiner programs refer to themselves as SANE programs. An FNE program includes the use of a clinician (usually a registered nurse or a nurse practitioner) who conducts the forensic examination of the sexual assault victim (Lang, 1999). Forensic nursing is the application of nursing science to public or legal proceedings that involve the investigation or treatment of trauma or death of victims and perpetrators of criminal violence. The clinician is specially trained in forensic evidence collection, sexual assault trauma response, forensic techniques using specialized equipment, expert witness testimony, assessment of injuries, STD treatment, and pregnancy evaluation and treatment (Cohen et al., 1996; Ledray & Berry, 1998). Recommendations: The medical system should promote the development of FNE programs by collaborating with other systems in the formation of the program. Utilization of medical facilities for the location of the FNE program can be an important resource that the medical

Forensic Nursing

community can offer. Many FNE programs are located within medical facilities such as EDs, women’s health centers, and community health departments. FNE programs should be developed by a multidisciplinary task force including, but not limited to, sexual assault survivors; sexual assault program staff; hospital administrators; ED personnel including medical directors, physicians, and nurses; local law enforcement agencies; probation officers; court judges; county and city prosecuting attorneys; prosecutor’s office victim advocates; and state police crime lab personnel. In addition, the task force should reflect the diversity of the community and include representatives from various cultural and other special populations in the community. All FNE programs should establish protocols and procedures to ensure the separation of team roles. Additional safeguards should be in place to maintain the actual and perceived neutrality and objectivity of the program, the credibility of the FNE, and the integrity of the forensic evidence collected. This is especially important for community-based FNE programs. FNE programs should include an on-site response by a sexual assault advocate. Although FNEs are trained in understanding sexual assault trauma response and are concerned for the emotional well-being of the patient, an advocate is able to provide support, advocacy, and validation so that the FNE can maintain his or her objectivity to preserve the forensic value of the physical exam. These roles should be clearly defined. When an FNE program is not located in a hospital, an agreement should be negotiated with the local hospital so that the FNE has access to the hospital facilities to conduct the forensic exam if the victim needs to remain in the hospital for injuries or does not wish to transfer to another location. FNE programs should be developed and operate with the holistic care of the patient being the primary focus. The forensic examination is performed for the purpose of treatment and diagnosis of a medical condition (sexual assault), and as such, the FNE can often testify to statements (made by the patient) as a medical exception to hearsay. In FNE programs it is important to base practice on sound nursing principles.

6.8.5 GENERAL CONSIDERATIONS FOR HEALTH CARE DELIVERY When caring for victims of sexual violence, the overriding priority must always be the health and welfare of the patient. The provision of medico-legal services assumes secondary importance to that of general health care services, such as the treatment of injuries, assessment and management of pregnancy, and STIs. Performing a forensic examination without addressing the primary health care needs of patients is negligent. Concern for the welfare of the patient extends to ensuring that patients are able to maintain their dignity. Medical and forensic services should be offered in such a way to minimize the number

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of invasive physical examinations and interviews the patient is required to undergo. 6.8.5.1 Ethical Issues It is a fundamental duty of all health care providers to use their professional skills in an ethical manner and observe the laws of the community. When providing services to victims of sexual violence, the following principles are generally considered to be fundamental: •

• • •

Autonomy: The right of patients to make decisions on their own behalf. All steps taken in providing services are based on the informed consent of the patient. Beneficence: The duty or obligation to act in the best interests of the patient. Nonmalfeasance: The duty or obligation to avoid harm to the patient. Fairness: Doing and giving what is rightfully due.

Health care professionals, in following the oath of “First, do no harm,” must also be aware of the needs and wishes of the patient, must display sensitivity and compassion, and must maintain objectivity. 6.8.5.2 Timing of Health Care Delivery

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a process that is considered to be inefficient, unnecessary, and most important, places an unwarranted burden on the victim. Ideally, medico-legal and health services are provided in the same location and preferably by the same health care practitioner. Policymakers and health care professionals are encouraged to develop this model of service provision. For a look at one such model, the Family Justice Center located in San Diego, see chapter 7. Because sexual assault victims present at any point along the health care continuum, all health care facilities should be able to recognize sexual abuse and provide services to victims of sexual violence, irrespective of whether a forensic examination is required. If not already in place, health care facilities must develop specific policies and procedures for dealing with victims of sexual violence. Given appropriate knowledge and training, any health care provider should be able to provide first-level service to victims of sexual violence. Expertise in the field will develop with further training, professional support, and adequate resources. Ideally, all health care providers who come into contact with victims of sexual violence should receive appropriate training; this applies particularly to nurses and physicians who conduct physical examinations of victims of sexual violence and to those who provide services to children and to the courts. In addition to initial training, health care practitioners should also be given the opportunity to further their education and training and to participate in quality control and peer review processes. In many settings, the sex of the health care provider might be a critical issue. Directors or managers of health care facilities should ensure that female nurses or physicians are available whenever possible. If necessary, efforts to recruit female examiners should be a priority.

The timing of the physical examination is largely dictated by what is best for the patient (particularly when injury intervention is required), but for a number of reasons, is best performed as soon as possible after the patient presents. Delay in accessing services could result in lost therapeutic opportunities, such as provision of emergency contraception; changes to the physical evidence, including healing of injuries; and loss of forensic material, the evidence of contact with the assailant.

6.9 THE MEDICO-LEGAL EXAMINATION ENVIRONMENT

6.8.5.3 The Setting of the Examination

6.9.1 FACILITIES

Appropriate, high-quality care should be available to sexual assault victims. Consultations and examinations should take place at a site where there is optimal access to the full range of services and facilities that might be required by the patient, for example. Victims should be able to access services 24 hours a day; if it is not possible to keep facilities open all the time (e.g., due to financial constraints), outside normal working hours, access could be provided on an on-call basis. Regardless of the setting and location, experts say care should be ethical, compassionate, objective, and above all, patient centered. Safety, security, and privacy are also important aspects of service provision. In many regions and states, the health and medico-legal components of the service are provided at different times, in different places, and by different people,

The ideal location for a health care facility for sexual violence victims is either within a hospital or a medical clinic, or somewhere where there is immediate access to medical expertise. Although most SANE programs are hospital based and located in the ED, there is a growing trend toward locating SANE programs outside of a health care institution. Because the credibility of the SANE has been established and is becoming increasingly accepted, and because research shows many victims sustain injuries requiring ED care, close medical supervision of the SANE’s practice is required. Wherever the practice is based, ideally, there should be at least two rooms: a waiting room and reception area plus a separate consulting and examination room (preferably with access to a toilet and waiting facilities). If the facility is providing services to

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children, the physical surroundings should be child-friendly and special equipment for interviewing the child, such as two-way mirrors or video-recording facilities, might be necessary. When it comes to equipping the examination room, financial resources are likely to be the main factor in determining the quality and quantity of equipment that can be provided and maintained by any given facility. The type of equipment and volume of supplies needed will depend on the types of services offered, the location of the health care facility, and the level of access to other medical services. When considering equipment needs, service providers should consider carefully the relevance of rape kits and laboratory services to their own situation. The fundamental requirements for facilities that treat sexual assault victims include: •

•

• •

Accessibility: Services should be accessible 24/7 if possible, or with health care providers on-call around the clock. Security: There should be adequate infrastructure in place to protect patients, staff, health records, and the facility itself. Cleanliness: A high standard of hygiene is required in the provision of any medical service. Privacy: Unauthorized people should not be able to view or hear any aspects of the consultation, so the examination rooms should have walls and a door, not merely curtains. Assailants must be kept separate from their victims.

Most important, victims need a private, discreet suite with ready access to an ED, comprising: 1. An examination room, equipped with an examination table. This space should: • Be of a comfortable temperature for the victim. • Have auditory and visual privacy. • Have clean table paper and a gown for each patient. • Have lighting sufficient to perform a genitoanal examination. • Have handwashing facilities. • Have well-organized and fully stocked forensic supplies. • Have a table or desk for documenting and for labeling specimens. • Have a lockable door to prevent entry during the examination. • Have access to a telephone. 2. A separate room containing a table and chairs where a support person could talk with the patient, and facilities for offering patients refreshments and a change of clothing.

3. A shower and toilet for the patient. 4. A room for the police. 5. A reception area that could also be used as a room for waiting family and friends (WHO, 2003).

6.9.2 EQUIPMENT

AND

SUPPLIES

The well-stocked examination suite should have the following items readily accessible: 6.9.2.1 General Medical Supplies • • • • • • • • • •

Syringes, needles, and sharps container Sterile swabs Blood-collection tubes Speculums in various sizes Sterilizing equipment for sterilizing specula Proctoscope/anoscope Examination gloves Pregnancy testing kits STI testing/collection kits Lubricant, sterile water, or normal saline solution

6.9.2.2 Forensic Supplies • • • • • •

• • • •

Swabs for collection of foreign material on victim such as semen, blood, or saliva Containers for transporting Microscope slides for the plating of swabs Blood-collection tubes for DNA or toxicological analysis Urine specimen containers for pregnancy and toxicological testing Sheets of paper or a clean white sheet for the patient to stand on while undressing for collection of loose, fine trace-evidence materials Paper bags for collection of clothing Drying cabinet to dry wet items of clothing Tweezers, scissors, and a comb for collecting foreign debris on skin and hair Ruler for measuring the size of wounds, and a scale for forensic photography

6.9.2.3 Treatment Supplies • • • • •

Analgesics Emergency contraception Suture materials Tetanus and hepatitis prophylaxis and vaccination STI prophylaxis

6.9.2.4 Linen Supplies • •

Sheets or paper for the or examination table Towels

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• • •

Clothing to replace any damaged or retained items of the victim’s clothing Patient gowns to allow the patient to fully undress for examination Sanitary items such as pads and tampons

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collection must include oral, vaginal, and anal samples, as appropriate. Step 1: Clothing •

6.9.2.5 Sundry Supplies • • •

Camera and film for photo–documentation of injuries Colposcope or magnifying lens for obtaining a magnified view of a wound Microscope to check for the presence of sperm, particularly if no laboratory facility is accessible

•

6.9.2.6 Documentation Supplies • • • • •

Examination record for recording findings Labels for attaching to specimens Consent form Pathology and radiology referral forms Information brochure to provide the patient with information about referral and follow-up services

6.9.3 SPECIAL CONSIDERATIONS

•

•

6.9.3.1 Sexual Assault Kits Rape kits are prepackaged kits that contain all the items typically required when collecting evidentiary material from victims. A rape kit readily provides busy clinicians with all of the materials required for the collection of evidence, making thenm readily accessible when needed. In addition, the contents can act as a prompt for inexperienced practitioners to take certain specimens. It also ensures that specimens are collected and packaged in such a way that is acceptable to the forensic laboratory. A disadvantage of prepackaged kits is their cost; typically, the monetary value of the individual parts is relatively small, but costs involved in the preparation and packaging of the kit add considerably to the overall price. In some cases, only a small number of the items in the kit are used, and the rest are wasted. An alternative to using prepackaged rape kits is to gather the various required items, such as swabs and slides, to create a customized rape kit from a stock of individual items. Custom-made rape kits also have the advantage of flexibility and can evolve as the facility becomes better resourced. According to Ledray (1999) in the Sexual Assault Nurse Examiner Development and Operation Guide, before samples for a sexual assault kit are collected, “a dialogue among the health care, forensic, and legal entities involved should occur.” Samples and collection techniques vary according to jurisdiction and will evolve as technology advances. According to the Guide, basic evidence

•

Place a clean hospital sheet on the floor as a barrier, then place collection paper on the barrier sheet. The examiner must be careful to prevent evidence transfer and should change his or her gloves whenever cross-contamination could occur. Document all findings. Have the patient first remove the shoes and then undress over the collection paper to catch any debris that is dislodged. Collect only clothing pertinent to the assault. Place each piece of clothing and collection paper in a separate paper bag, label, seal, and initial the seal. Collect shoes, if pertinent. If additional bags are needed, use grocery-style paper bags only. Tape or seal bags closed; label, seal, and initial the seal. Collect obvious debris from the patient’s body, including any plant material, fibers, hair, soil, and so on, on the sheet of paper provided, then bundle, label, seal, and initial the seal. If fingernail scrapings are collected, place the fingernail scrapings and the tool used to obtain the sample in a paper, bundle, label, seal, and initial the seal. If fingernails are broken, cut the remaining jagged edge for later comparison. Collect decorated fake nail as a known sample if one fake nail is missing. Place the patient in an examination gown.

Step 2: Dried Secretions • •

• • •

Inspect the body carefully for dried secretions, bruises, bite marks, and burns. Place flake-dried secretions into a paper bundle or swab dried secretions with a swab moistened with one drop of water; or smear swabs onto two microscope slides. Air dry all specimens, then label, place in an envelope, seal, and initial the seal. Photograph all bite marks and swab them for trace evidence using the double-swab technique. Swab the bite marks as well as all areas the perpetrator might have kissed, licked, or sucked.

Step 3: Oral Sample •

•

Place two swabs together to collect a specimen from the oral cavity between gums and cheeks and under tongue; remove dentures and swab with same swabs. Air dry slides and swabs.

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• •

Place slides in holder and swabs in carton; place in envelope. Label and seal the envelope, then initial the seal.

Step 4: Head Hair Combing • •

• •

Remove paper and comb provided in envelope; patient can do the combing. Unfold and place paper under the patient’s head. Using comb provided, comb head hair toward the paper. If hair is matted because of stains, cut the matted hair and place on the collection paper. Place the comb in the center of the paper and fold into bundle with comb inside. Label, place in envelope, seal, and initial the seal.

Step 5: Optional Pulled Head Hair (Can Be Delayed at the Discretion of Law Enforcement and the Patient); Patient Can Collect Hairs • • •

•

• •

Remove paper bundle and unfold. Use fingers; do not use forceps or tweezers. Pull, do not cut, a minimum of eight full-length head hairs from top, front, back, left side, and right side. Collect unusually colored or dyed hairs; collect hairs from wigs and hairpieces; place in separate bundle, label, and place in collection paper. Place hairs in bundle and refold. Label and seal envelope; initial the seal.

Step 6: Pubic Hair Combing • •

• •

Place collection paper under patient’s buttocks and comb hair toward the paper. Collect secretions dried on the pubic hair by cutting the matted hair and placing on the collection paper. Fold comb with debris and matted hair into paper; place folded paper in envelope. Place in envelope, label, seal, and initial the seal.

Step 7: Pulled Pubic Hair (Can Delay Collection Until and if Requested by the Forensic Laboratory) • • • • • • •

Remove paper bundle and unfold. Pull the hair (do not cut). Use fingers only, as tweezers or forceps crimp the hair. Pull a minimum of 25 hairs from all areas of the pubis. If debris or semen is matted in the hair, cut it out and add to the pubic hair sample bundle. Place hairs in the bundle and refold. Place in envelope, label, seal, and initial seal.

Step 8: External Genital Sample • • •

• •

Swab the external genital area with two swabs, rolling swabs together as you collect. Smear the swabs on the two microscope slides. Air dry swabs and slides for 60 minutes. If drying or desiccant agents are used, swabs must be packaged inmediately. Package swabs and two desiccant packs in an airtight container or glassine envelope folded over to be airtight. Place slides in holder and swabs in cartons. Place in envelope, label, seal, and initial the seal.

Step 9: Toluidine Blue Toluidine blue dye (1 percent aqueous solution) is used in sexual assault examinations to aid in the identification and documentation of lacerations. Toluidine blue does not stain the surface layer of skin but will dye nucleated squamous cells in deeper layers of the epidermis exposed by even superficial lacerations. It has increased detection of trauma in children, adolescents, and adults, and it can be applied in cases suspicious for both genital and anal trauma. If used as part of the female genital exaimnation, it should be applied by cotton swab before any internal digital or speculum examination to ensure that any injuries noted are not induced by the examiner. The examiner should be careful not to allow the dye to enter the vaginal vault. The vaginal application of the dye should occur after the anal application has been completed (if indicated) to avoid any cross-contamination. Excess dye can be blotted away with 1 percent acetic acid solution (1 percent vinegar/water) or lubricating jelly. Specific injuries identified at the posterior fourchette are most consistent with trauma from recent sexual intercourse. Use of toluidine might be unnecessary if a colposcope is available or if obvious trauma is visible. Toluidine cannot separate consensual from nonconsensual lesions. Nontraumatic inflammatory or infectious lesions will be positive. Toluidine might be useful in illuminating injuries for nonmedical persons, including jurors in a courtroom setting. The steps are as follows: 1. Collect all external genital specimens as indicated by examination protocol before toluidine blue dye application. 2. Photo-document the area. 3. Apply toluidine blue dye by using a sterile cotton swab to the genital area in question. Dye application can be used on the labia majora, labia minora, posterior fourchette, penneal body, and penanal area. 4. Gently blot away excess dye with 1 percent acetic acid or lubrication jelly. 5. Photo-document area after dye application. 6. Speculum examination and other procedures can be commenced.

Sexual Assault

Step 10: Anal Sample The examiner must consider local policy, potential issues of patient needs and wants, and the need for collection of evidence from appropriate parts of the body. There are times, however, when a patient will deny anal touching or penetration because of embarrassment, and valuable evidence would be lost. It is suggested that a routine anal swab be requested of each sexual assault patient, at the same time making it clear that, as with any other part of the examination, it can be declined after the patient is informed. The examiner must also consider the likelihood of a positive test, potential trauma to the patient, and the need to collect immediate evidence. •

•

• •

Use an alternative light source on anal area and flake off or swab areas of dried secretions, place on slide (optional), air dry, and place in envelope labeled “perianal.” Use two swabs together to collect a sample from the anal cavity (avoid contact with external skin surfaces). Air dry, place in holders, and place in envelope. Label and seal envelope, and initial the seal.

Step 11: Vaginal/Penile Sample • •

• •

•

Use two swabs together to collect specimen from vaginal pool. Optional: Smear one swab on slide for wet mount; slide is prepared by placing one drop of normal saline onto slide. Roll swab into drop and cover with a coverslip. View for presence of motile sperm under 400x (within 10 minutes). Package this swab and slide separately and label as “wet mount.” Optional: Smear other swabs onto slides. Air dry all swabs and slides, place in appropriate holders (wet mount slide goes into single slide holder), and place in envelope. Label and seal envelope, and initial the seal.

Step 12: Optional Vaginal Washings • • •

Use 3 mL of sterile saline or water for vaginal lavage (use plastic catheter and 3 mL syringe). Aspirate and place in tube provided. Tightly secure cap. Label, place in envelope, and seal envelope; initial the seal.

Step 13: Toxicology • •

Collect a urine sample if drug or alcohol ingestion is suspected. If possible, perform the vaginal examination (if applicable) before collecting the urine sample.

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• • • •

Collect urine in a specimen cup. Label, seal, and initial the seal. Do not place the urine sample in the kit; package it separately according to local protocol. To collect a blood sample (if drug ingestion up to 12 hours), collect three Vacutainer tubes (30 mL total).

Step 14: Optional Known Reference Sample • • •

• •

A buccal swab can be used instead of blood sample, depending on the jurisdiction. Remove sterile swab from envelope. Have the patient rinse his or her mouth with tap water, and then expose buccal (inner) area of cheek. Swab with gentle pressure. Place in envelope, label, seal, and initial the seal.

Bite Mark Guidelines According to guidelines from the American Board of Forensic Odontology, forensic examiners should include a clear and complete description of the bite mark. The following demographic information should be collected: patient’s name; case number; date of the assault; date of the examination; and the age, race, and sex of the patient. The examiner’s name should be included. The following should be noted when documenting a bite mark: • • • • • • • • •

•

Location of bite mark Description of the anatomic location Describe surface contour: flat, curved, irregular Description of tissue characteristics Description of the underlying structure: boric, cartilage, muscle, fat Description of the skin, whether relatively fixed or mobile Description of the shape: round, ovoid, crescent, irregular, double Description of the color: red, purple, and so on Description of the size, including vertical and horizontal dimensions of the bite mark; the distance between canines; the circular arc should be documented with a metric scale such as the ABFO #2 scale; the presence or absence of suction applied to the bite area should be documented when possible Description of the type of injury: petechial hemorrhage, contusion, abrasion, laceration, incision, avulsion, or artifact

The gathering of bite mark evidence should be done with authorization from the patient. Note whether the bite mark has been affected by washing, contamination, lividity,

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change of position, and other factors. Bite marks should be documented through proper photography. Orientation and close-up photographs with and without a metric scale marker should be taken, with identifying information such as the case number, date, initials of the examiner, and so on included in the photographs. Photographic resolution should be of high quality (a macro lens with ring and point flash). If color film is used, accuracy of color balance should be ensured. In using the scale (including a circular and linear scale), ensure that it is on the same plane and adjacent to the bite mark. The ABFO #2 scale incorporates both of these elements. Ultraviolet light can be used to photograph bite wounds months after they occur, even when the overlying skin appears normal. This method should be used when historically indicated. The most critical photographs should be taken in a manner that will eliminate distortion. Some high-end 35mm cameras have interchangeable focusing screens. Use of an architectural grid screen in conjunction with the ABFO #2 scale will help reduce distortion. It is also beneficial to obtain serial photographs of the bite mark over a period of time. Whenever possible, salivary trace evidence should be collected as guided by the patient history and the use of an alternative light source. Examiners should use the double-swab technique to collect the saliva, taking the following actions: • • • • • • • •

Immerse the tip of the first swab in water. Roll the tip of the swab over the skin, using moderate pressure and circular motions. Air dry the swab for 60 minutes. Do not moisten the second swab, but use it dry. Roll the tip of the swab over the skin, using moderate pressure and circular motions. Air dry the swab for 60 minutes. Package both swabs together in a paper envelope, label, and seal. Do not lick the evidence envelope because it will contaminate the sample.

restraints; drugs used to facilitate sexual assault; choking; burns; ingestion of a foreign substance) • Injuries inflicted on assailant(s) during assault • Acts described by patient • If more than one assailant, identify by number 2. Document the following acts and whether a penis, finger, or other object was used: • Penetration of labia majora (vulva or deeper structures) • Penetration of anus or deeper structures • Oral copulation of genitals • Oral copulation of anus • Nongenital acts • Biting of patient or by patient on perpetrator • Licking • Kissing • Other acts • Did ejaculation occur? If yes, note location: vulva or deeper structures; anus or deeper structures; body surface; mouth; bedding; clothing • Contraceptives or lubricant products used • Recent consensual intercourse Performing the General Physicial Examination and Documenting Findings • • • • • •

• •

Taking the Assault History 1. Document the patient’s description of the encounter in direct quotes if at all possible, including the following details: • Date of assault(s) • Time of assault(s) • Physical surrounding of assault(s) • Lapse of consciousness • Nongenital injury, pain, and/or bleeding • Anogenital injury, pain, and/or bleeding • Verbal coercion • Force or coercion used (including weapons threatened or used; physical assault; grabbing, holding, or pinching; physical

• • •

Vital signs Date and time of examination General physical appearance General demeanor, behavior, and orientation Description of clothing on arrival Conduct physical examination and document, draw, number injuries and findings, including size and appearance, on a diagram and use a legend for abbreviations or numbers (be specific) Alternate light source examination Collect dry and moist secretions, stains, and foreign materials from the body and from the nose, mouth, and genitals Collect fingernail scrapings or cuttings Examine the oral cavity for injury Swab the areas the suspect kissed, licked, or sucked

Laboratory Services Specimens collected from victims can be broadly divided into two categories: those used for diagnostic health purposes and those used for criminal investigation. In most settings, the type of specimens collected for the purpose of forensic investigation will be dictated by the quality and sophistication of available services at medico-legal or forensic laboratories. For instance, if a laboratory is not

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able to perform DNA testing (or access such testing from another laboratory), there is little point in collecting specimens for DNA analysis. By the same token, there is little use for expensive rape kits if immediate access to highquality analytical services is not available. Health care providers are advised to consult laboratory staff as to which specimens they are able to process, how samples should be collected and handled, and how long the samples will take to process. Examination Records There are a number of different ways of recording the details of a consultation with a victim; however, use of a standard form is generally considered to be the most convenient and reliable method. Consideration must also be given to matters of confidentiality; completed records must be stored securely and accessed only by authorized staff. The Colposcope The colposcope is a binocular, low-powered microscope with an integral light source. Most colposcopes have an attachable camera that allows findings to be photographed or videotaped. In recent years, the colposcope and its capacity for photo-documentation have greatly assisted the recording of genito-anal findings in abused and nonabused children. However, colposcopes are expensive and some skill is required in the interpretation of recorded findings. Genito-anal examinations conducted by an experienced person using a fixed light and a hand-held lens are generally considered to be adequate and are still the norm in many areas. Exam Equipment The hospital ED or clinic where the exams are being completed is often willing to donate exam supplies. In many states, the rape exam kits are provided by law enforcement at no charge. Standardized kits can also be purchased when they are not available free from law enforcement. Consult with the local state crime laboratory that will be analyzing the evidence collected before purchasing the kits. Because the price and contents of standardized kits vary greatly from manufacturer to manufacturer, ask to have a sample sent for review before making a decision to purchase a particular kit. The crime laboratory might know where to purchase standardized kits, as they are available from a number of sources. Law enforcement agencies often pay for this cost because use of standardized kits benefits law enforcement by promoting better evidence collection. Emphasize this benefit to the law enforcement agency when negotiating with them to provide these kits. Further discussion of this issue follows later in this chapter. A Polaroid, digital, or 35mm camera will also be needed. Before making the purchase, check to see if the ED or clinic where the exams will be completed already has one available that the SANE could access. Small

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35mm cameras with automatic focus that are easy to operate and will take adequate pictures of injuries are available for as little as $100. A camera with a macro lens attachment will produce higher quality, close-up photos. Later, when the budget allows, the camera equipment can be upgraded. Do not be tempted to get camera equipment that is so sophisticated that the staff will have trouble using it effectively. Also, ensure that the cost of film and film development is covered in the budget if these costs, which can be considerable, are not reimbursed by law enforcement or the prosecutor’s office. If the budget allows, consider purchasing a digital camera that can transmit photo evidence directly to the police department, if it is utilizing this technology. The police department might even be willing to provide the SANE program this equipment, recognizing the value to the investigative efforts of its department. Another consideration is photographic equipment that captures ultraviolet images. Although more sophisticated, it is very effective in identifying and highlighting bruising, especially in women of color. Although this technology was once controversial and its accuracy was challenged in the courtroom, its scientific value is now widely accepted. The use of a digital camera, however, must be discussed with the local prosecuting attorney’s office because digital imagery can be altered easily and, consequently, it might not be accepted by that office. Forensic photo-documentation is discussed further in chapter 5. An alternate light source will also be needed. Much like the camera, these light sources are typically available in the ED or clinic for eye exams. If the budget is tight, arrange to have access to the equipment rather than to purchase it. If the SANE program is located in a separate clinic, a pelvic examination table also must be acquired. A microscope might be necessary to observe wet mounts for motile sperm. Additional equipment that will soon become a standard, but is still not available to many SANE programs because of the cost, are the colposcope ($10,000–$15,000 for the colposcope alone); light-staining microscope ($1,000 to $1,500); digital camera systems with direct computer links; and video equipment with print capabilities. Because of the excessive cost of the colposcope, some programs, especially those working with children, have chosen instead to purchase MedScope ($3,500; $11,500 including camera, internal lens, camera holder, monitor, printer, foot switch, VCR, and cart).

6.9.4 THE INITIAL ASSESSMENT 6.9.4.1 Conduct of Health Care Providers How health care professionals conduct themselves is of vital importance in the treatment of sexual assault victims. A victim is often in a heightened state of awareness and very emotional after an assault. Many survivors of sexual

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assault have described the kindness of the treating personnel as being beneficial to their recovery. Health care providers must choose their words with great care when dealing with sexual assault patients and take care not to contribute in any way to revictimization of the patient. Use of insensitive language can not only contribute to patient distress during the examination but also hinder long-term recovery. Health providers are advised to choose words that are gentle and soothing; there is no place for judgmental or critical comments. It is imperative that all victims of sexual violence are treated with respect and dignity throughout the entire examination irrespective of their social status, race, religion, culture, sexual orientation, lifestyle, sex or occupation. Many victims cite a fear of not being believed as a reason for not reporting sexual assault and, indeed, recovery can be hindered when others disbelieve or blame the patient for the assault. Validation of the patient’s feelings is thus critical to recovery. Body language, gestures, and facial expressions all contribute to conveying an atmosphere of believing the patient’s account. However, this does not relieve the health worker from his or her duty to consider carefully what he or she is being told. There is a big difference between skepticism and naivete, and it is in between these polarities that the health care provider can best satisfy the differing needs of patient, law enforcement, criminal justice system, and the wider society. To be seen to be impartial is vital for effective court testimony. Health care providers should also be aware of the impact on themselves of repeatedly hearing, seeing, and dealing with cases of IPV. 6.9.4.2 Demeanor of the Health Care Provider The following strategies and techniques might be helpful when dealing with victims of sexual violence: • • • •

• • •

Greet the patient by name. Introduce yourself to the patient and explain your role. Aim for an attitude of respectful, quiet professionalism. Have a calm demeanor, as a victim who has been frightened and has experienced fear should be in the company of people who are not frightened. Be unhurried and make the victim the focus of your attention. Maintain eye contact as much as is appropriate. Be empathetic and nonjudgmental as your patient recounts his or her experiences.

6.9.4.3 Obtaining Consent Before a full medical examination of the patient can be conducted, it is essential that informed consent be

obtained. In practice, obtaining informed consent means explaining all aspects of the consultation to the patient. Particular emphasis should be placed on the matter of the release of information to other parties, including the police. This is especially important in settings where there is a legal obligation to report an episode of violence (and hence details of the consultation) to the relevant authorities. Thus, having determined the medical status of the patient, the next step in the assessment process is to inform the patient of his or her options. It is crucial that patients understand the options open to them and are given sufficient information to enable them to make informed decisions about their care. It is important that the correct environment is provided (i.e., one in which the patient feels secure and does not feel pressured or intimidated in any way). This is a fundamental right of all patients but has particular relevance in this setting where patients might have been subjected to a personal and intrusive event against their will. It is also important to ensure that patients have a sense of control returned to them when in medical care. Above all, the wishes of the patient must be respected. Informed consent is a central issue in medicolegal matters. Examining a person without his or her consent could result in the examiner being charged with offenses of assault, battery, or trespass. In some jurisdictions, the results of an examination conducted without consent cannot be used in legal proceedings. 6.9.4.4 Taking a History Once you, as the examiner, are satisfied that the patient has sufficient information to provide informed consent, ask him or her to sign or mark the consent form (if a consent form is required in your jurisdiction). Explain to the patient that should he or she decide to pursue legal action against the perpetrator, any information he or she discloses to you in the course of the examination might become part of the public record. If mandatory reporting is required in your jurisdiction, make sure the patient understands this. It is worth spending time obtaining consent as this could help to develop the patient’s trust in you. It will benefit everyone if you can make your patient feel safe and secure in the environment in which you are working, as well as with yourself, as his or her examiner. 6.9.4.5 Obtaining a General Medical History The primary purpose of taking a medical history is to obtain information that might assist in the medical management of the patient or might help to explain subsequent findings, such as easy bruising, loss of consciousness, or memory loss. Health professionals are advised to refer to national guidelines or standards for conducting clinical examinations to ensure that they are in compliance. At a minimum, the medical history should cover any known

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health problems, immunization status, and medications. If possible, a standard examination record should be used for recording details of the patient’s medical history; use of a standard form acts as a guide for the examiner by prompting relevant questions and prevents the omission of important details. Observing an experienced practitioner taking a history is also an invaluable aid in this area.

•

6.9.4.6 Obtaining an Account of the Assault

•

The main objectives of obtaining an account of the assault are to do the following:

•

• • • • •

Detect and assess injuries. Assess the risk of adverse consequences, such as pregnancy and STIs. Facilitate relevant evidence collection. Facilitate documentation. Guide forensic examination.

When interviewing the patient about the assault, ask him or her to tell you in his .or her own words what happened. Document the account without unnecessary interruption; if you need to clarify any details, ask questions after your patient has completed his or her account. Avoid questions commencing with the word, “Why?” as this tends to imply blame; instead use open-ended, nonleading questions. Be thorough, bearing in mind that some patients might intentionally avoid particularly embarrassing details of the assault (e.g., patients might omit details of oral sexual contact or anal penetration); others might find it difficult to talk about the assault. Explain to the patient that you are interested in different aspects of the event to the police; as his or her health care provider, you are particularly concerned about any physical contacts between the patient and his or her assailants. The following details about the alleged assault must be documented: •

• • • • •

Date, time, and location of the assault, including a description of the type of surface on which the assault occurred Name and identity (if nonstranger) and number of assailants Nature of the physical contacts and detailed account of violence inflicted Use of weapons and restraints Use of medications, drugs, alcohol, or inhaled substances How clothing was removed

Details of actual or attempted sexual activity should also be carefully recorded, in particular whether or not the following occurred:

• • •

Vaginal penetration of victim by offender’s penis, fingers, or objects Rectal penetration of victim by offender’s penis, fingers, or objects Oral penetration of victim by offender’s penis or other object Oral contact of offender’s mouth with victim’s face, body, or genito-anal area Forced oral contact of victim’s mouth with offender’s face, body, or genito-anal area Ejaculation in victim’s vagina or elsewhere on the victim’s body or at the scene

The use of condoms and lubricant should be noted. Any subsequent activities by the patient that might alter evidence (example.g., bathing, douching, wiping, the use of tampons, and changes of clothing) should also be documented. Finally, details of any symptoms that have developed since the assault must be recorded, including genital bleeding, discharge, itching, sores or pain; urinary symptoms; anal pain or bleeding; and abdominal pain. 6.9.4.7 The Physical Examination When conducting a physical examination of a victim of sexual violence, examiners are advised to proceed as follows: 1. Note the patient’s general appearance, demeanor, and mental functioning. If the patient’s mental functioning appears impaired, attempt to assess whether the impairment is recent or symptomatic of a longer term illness or disability. 2. Note the patient’s vital signs: blood pressure, temperature, pulse, and respiration rate. 3. Examine the patient from head to toe, concluding with the genito-anal area. 4. Note and describe in detail any physical injuries, even if forensic evidence is not being collected. Use body maps to indicate location and size of injury. 5. Photograph any injuries. 6. Order diagnostic tests (e.g., x-rays, CT scan, ultrasound) to aid in diagnosing fractures, head and neck injuries, brain or spinal cord injuries, or abdominal trauma. 7. Draw blood samples for testing for HIV (informed consent must be obtained for HIV testing), hepatitis B, syphilis, and other STIs. It is important to observe the following general principles and procedures throughout the examination: •

Before starting the physical examination, take time to explain all of the procedures to your

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• •

•

• •

•

•

patient and why they are necessary. Give your patient a chance to ask questions. Allow the patient to have a family member or friend present throughout the examination. A chaperone for the patient should always be present, especially if the examiner is male. The primary role of the chaperone, preferably a trained health worker, is to provide comfort and support to the patient. The chaperone also protects the health care provider in the event of a patient alleging that the examining health care provider behaved in an unprofessional manner. Throughout the physical examination inform the patient what you plan to do next and ask permission. Always let the patient know when and where touching will occur. Show and explain instruments and collection materials. Patients can refuse all or parts of the physical examination and you must respect the patient’s decision. Allowing the patient a degree of control over the physical examination is important to his or her recovery. The examination should be performed in a setting that is light, warm, clean, and private. If the clothing removed was that worn during the assault and forensic evidence is to be collected, the patient needs to undress over a white sheet or large piece of light paper. Try to provide as much privacy as possible while the patient is undressing. Use a cover gown. If the patient has consented to the collection of his or her clothing, each item of clothing must be placed by the examiner’s gloved hand into a paper bag. If clothing is to be held for forensic examination, replacement clothing needs to be provided. Both medical and forensic specimens should be collected during the course of the examination. Providing medical and legal services simultaneously reduces the number of examinations the patient has to undergo and can ensure the needs of the patient are addressed more comprehensively. The following standard precautions should be observed at all times during the examination to prevent transmission of infectious agents: 1. Wear gloves whenever in contact with blood or other body fluids. 2. Change gloves between patients; it might sometimes be necessary to change gloves during the examination to prevent contamination. 3. Wash hands with soap and water after any exposure to body fluids or blood, between clients, and after removing gloves.

•

•

4. Wear protective eyewear, masks, or face shields if there is a possibility of splashing blood or body fluids into your eyes, face, or mouth. 5. Do not recap used needles, do not bend or break needles after use, and dispose of used needles in special impermeable sharps containers immediately after use. The health care provider should document all findings as the physical examination proceeds. The patient can thus expect periods of silence during the course of the examination. Make sure that the patient understands that he or she can stop the procedure at any stage if it is uncomfortable for him or her and give him or her ample opportunity to stop the examination, if necessary. Always address patient questions and concerns in a nonjudgmental, emphatic manner, and use a calm tone of voice.

6.9.4.8 The “Top-to-Toe” Physical Examination According to the WHO’s (2003) guidelines for the medico-legal examination, a systematic, “top-to-toe” physical examination of the patient should be conducted in the following manner: 1. First note the patient’s general appearance and demeanor. Take the patient’s vital signs. Start with the patient’s hands, inspecting both sides of both hands for injuries. Observe the wrists for signs of ligature marks. Trace evidence might need to be collected, including fingernail scrapings. 2. Inspect the forearms for defensive injuries, which occur when the victim raises a limb to ward off force to vulnerable areas of the body. Defensive injuries include bruising, abrasions, lacerations, or incised wounds. In dark-skinned individuals, bruising can be difficult to see, and thus tenderness and swelling is of great significance. Any intravenous puncture sites should be noted. 3. The inner surfaces of the upper arms and the armpit or axilla need to be carefully observed for signs of bruising. Victims who have been restrained by hands often display fingertip bruising on the upper arms. Similarly, when clothing has been pulled, red linear petechial bruising can sometimes be seen. 4. Inspect the face. Black eyes can be subtle. Look in the nose for signs of bleeding. Gentle palpation of jaw margins and orbital margins might reveal tenderness indicating bruising. The

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5.

6.

7.

8.

9.

10.

mouth should be inspected carefully, checking for bruising, abrasions, and lacerations of buccal mucosa. Petechiae on the hard or soft palate might indicate penetration. Check for a torn frenulum and broken teeth. Collect an oral swab, if indicated. Inspect the ears, not forgetting the area behind the ears, for evidence of shadow bruising, which develops when the ear has been struck onto the scalp. Use an otoscope to inspect the eardrum. Gentle palpation of the scalp might reveal tenderness and swelling, suggestive of hematomas. Hair loss due to hair pulling during the assault could cause large amounts of loose hair to be collected in the gloved hands of the examiner; alternatively, a gentle combing might recover any loose hair. Electrostatic forces can, however, cause large amounts of loose hair to be retained in the head until the patient next takes a shower or bath. The neck area is of great forensic interest. Bruising on the neck can indicate a life-threatening assault. Imprint bruising might be seen from necklaces and other items of jewelry on the ears and on the neck. Suction-type bruising from bites should be noted and swabbed for saliva before being touched. The breasts and trunk should be examined with as much dignity and privacy as can be afforded. It is generally most convenient to start with the back. It is possible to expose only that area that is being examined; for example, the gown can be taken aside on the right side of the back and then the left side of the back. The shoulders should be separately viewed. Subtle bruising and more obvious bruising might be seen in a variety of places on the back. If the patient is able to sit up on the examination table, the gown can be taken down to the upper breast level just exposing the upper chest on the right and left and then each breast can be examined in turn. Breasts are frequently a target of assault and are often bitten and so might reveal evidence of suction bruises or blunt trauma. If the breasts are not examined, the reasons for not doing so should be documented. The patient can then be reclined for an abdominal inspection for bruising, abrasions, lacerations, and trace evidence. Abdominal palpation should be performed to exclude any internal trauma or to detect pregnancy. With the patient still in a reclined position, the legs can be examined in turn, commencing with the front of the legs. Inner thighs are often the target of fingertip bruising or blunt trauma

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caused by the assailant’s knees. The pattern of bruising on the inner thighs is often symmetrical. There might be abrasions to the knee as a consequence of the patient being forced to the ground; similarly, the feet might show evidence of abrasions or lacerations. It is important to inspect the ankles (and wrists) very closely for signs of restraint with ligatures. The soles of the feet should also be examined. 11. It is advisable, if possible, to ask the patient to stand for the inspection of the back of the legs. An inspection of the buttocks is also best achieved with the patient standing. Alternatively, the patient can be examined in a supine position and asked to lift each leg in turn and then rolled slightly to inspect each buttock. The latter method might be the only option if the patient is unsteady on his or her feet for any reason, but does not afford such a good view of the area. Any biological evidence should be collected with moistened swabs (for semen, saliva, or blood) or tweezers (for hair, fibers, grass, or soil). As a general rule, the presence of any tattoos should be documented in the examination record, together with a brief description of their size and shape, as these might become a means of assessing the accuracy of the observations of the examining practitioner in court. Similarly, obvious physical deformities should be noted. If tattoos and obvious deformities are not recorded, the examiner should be prepared to justify his or her decision for not doing so. The examiner should weigh the evidential value of observations of this nature against the prejudicial value they might have when discussed in front of a jury on a case-by-case basis. The WHO guidelines state that the use of a Wood’s lamp to detect semen on areas of skin where this is suspected is no longer a recommended clinical practice, stating, “Wood’s lamps do not fluoresce semen as well as previously thought, and more reliable methods of detecting semen (e.g. swabs) should therefore be used.” 6.9.4.9 The Genito-Anal Examination Before embarking on a detailed examination of the genitoanal area, according to the WHO guidelines, it is important to make the patient feel as comfortable and as relaxed as possible. It will greatly assist many patients if each step of the examination is explained to them; for example, say, “I’m going to have a careful look. I’m going to touch you here to look a bit more carefully. Please tell me if anything feels tender.” Initially, the patient should be placed lying on his or her back with his or her knees drawn up, heels

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together, and legs gently flopped apart (in the lithotomy position). The patient’s breasts, abdomen, pelvic area, and legs can be covered by a sheet until the examination actually takes place, at which point the sheet can be drawn up. Lighting should be directed onto the patient’s vulval area. Injuries to the genital or anal regions can cause considerable pain when touched. In some instances, only a limited examination might be necessary; alternatively, analgesia might be required. The following procedures form the basis of a routine genito-anal examination: 1. The external areas of the genital region and anus should be examined, as well as any markings on the thighs and buttocks. Inspect the mons pubis. The vaginal vestibule should be examined, paying special attention to the labia majora, labia minora, clitoris, hymen or hymenal remnants, posterior fourchette, and perineum. A swab of the external genitalia should be taken before any digital exploration or speculum examination is attempted. A gentle stretch at the posterior fourchette area might reveal abrasions that are otherwise difficult to see, particularly if they are hidden within slight swelling or within the folds of the mucosal tissue. Gently pulling the labia (toward the examiner) will improve visualization of the hymen. Asking the patient to bear down might assist the visualizing of the introitus. 2. If any bright blood is present, it should be gently swabbed to establish its origin—whether it is vulval or from higher in the vagina. 3. A speculum examination allows the examiner to inspect the vaginal walls for signs of injury, including abrasions, lacerations, and bruising. (Use of a transparent plastic speculum is especially helpful for visualizing the vaginal walls.) Trace evidence, such as foreign bodies and hairs, might be found and, if so, collected. The endocervical canal can also be visualized. This part of the examination might be particularly difficult for the patient, as it might remind her of the assault. It should therefore be introduced gently and its importance explained carefully. Warming of the speculum prior to use is advisable and can be achieved by immersing the instrument in warm water in a sink. Traditionally, the recommended technique for speculum examinations involved inserting the speculum along the longitudinal plane of the vulval tissues and then rotating it into its final position once the initial muscle resistance had relaxed. More recently, however, an alternative technique, one that is generally more comfortable

for the patient, has gained widespread acceptance. The duckbill speculum is rested in its broader dimension on the posterior fourchette, allowing the dimension of the object to be anticipated by the vaginal tissues. This also allows some relaxation of the introital tissues prior to insertion, in much the same way as the perianal sphincters do when the examining digit is rested at the opening prior to insertion. With the duckbill speculum resting as described, and the patient in the lithotomy position, the speculum can be smoothly introduced, with no twisting, in a downward direction, opening the duckbills gently as it progresses. This avoids any contact with the urethra, which is painful, and allows the cervix to be visualized with ease. In most cases, a speculum examination should be performed as a matter of course. It is particularly relevant if there is significant vaginal or uterine pain postassault, vaginal bleeding, or suspicion of a foreign body in the vagina. Furthermore, in assaults that occurred more than 24 hours but less than 96 hours prior to the physical examination, a speculum examination should be performed to collect an endocervical canal swab (for semen). If a speculum examination is not conducted because of patient refusal, it might still be possible to collect a blind vaginal swab. 4. Although an anal examination can be performed while the patient is still in the lithotomy position, it is usually easier to do this with the patient in the left lateral position. Thus on completion of the genital examination, ask the patient to roll over on to her side and face the wall with her legs drawn up. Respectful covering of the thighs and vulva with a gown or sheet during this procedure can help prevent a feeling of exposure. The uppermost buttock needs to be lifted to view the anus. This should be explained. The patient can hold the buttock up herself, if she is comfortable and able to do so. Gentle pressure at the anal verge might reveal bruises, lacerations, and abrasions. 5. Digital rectal examinations are recommended if there is a reason to suspect that a foreign object has been inserted in the anal canal, and should be performed prior to a proctoscopy or anoscopy. In a digital rectal examination, the examining finger should be placed on the perianal tissues to allow relaxation of the natural contraction response of the sphincter. Once relaxation is sensed, insertion can take place. 6. Proctoscopy need only be used in cases of anal bleeding or severe anal pain postassault, or if

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the presence of a foreign body in the rectum is suspected. 6.9.4.10 Recording and Classifying Injuries Clinicians and pathologists are frequently required to respond to questions about injuries from investigators, lawyers, or the courts. The sorts of things that investigating teams want to know about are the following:

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abrasions, bruises, lacerations, incisions, stab wounds, or gunshot wounds. Describing features of physical injuries requires documentation of the following: • • •

• • • • •

The age of an injury The mechanism by which the injury was produced The amount of force required to produce the injury The circumstances in which the injury was sustained The consequences of the injury

Injury interpretation is a complex process requiring a broad comprehension of anatomical, physiological, and pathological principles. Individuals performing this role should have proven expertise in the field; this expertise should be reinforced by exposure to peer review, continuing education, and quality assurance programs. Without accurate documentation and expert interpretation of injuries, any conclusions drawn about how injuries occurred might be seriously flawed. This will have profound consequences for both the victim and the accused. 6.9.4.11 Injury Description Injury interpretation is entirely dependent on the accuracy and completeness of the recorded observations of wounds. Adoption of a systematic approach to describing and recording the physical characteristics of wounds will ensure that none of the critical elements is omitted. Ideally, such observations should be recorded contemporaneously in the notes of the medical consultation. 6.9.4.12 Classification of Wounds There are a number of advantages of using standard, universally accepted descriptive terms for classifying wounds. Use of a standard terminology not only assists in identifying the mechanism by which the injury was sustained but also contributes to a better understanding of the circumstances in which the injuries could have been sustained. When used correctly, a standardized system of wound classification and description might allow deductions about the weapon or object that caused the injury. Furthermore, an examination of the pattern of injuries could assist in answering questions about whether the injuries were sustained in an accidental, assaultive, or selfinflicted manner. Wounds are generally classified as either

• • • • • •

• •

Site: Record the anatomical position of the wounds. Size: The dimensions of the wounds should be measured. Shape: Describe the shape of the wounds, such as linear, curved, or irregular. Surrounds: Note the condition of the surrounding or the nearby tissues. Color: Observation of color is particularly relevant when describing bruises. Course: Comment on the apparent direction of the force applied. Contents: Note the presence of any foreign material in the wound, such as dirt, and so on. Age: Comment on any evidence of healing. Borders: The characteristics of the edges of the wounds might provide a clue as to the weapon used. Classification: Use accepted terminology wherever possible. Depth: Give an indication of the depth of the wounds; this might have to be an estimate.

6.9.4.13 Wound Categories 1. Abrasions are defined as superficial injuries to the skin caused by the application of blunt force and are produced by a combination of contact pressure and movement applied simultaneously to the skin. Careful examination of an abrasion might allow identification of the causative implement and the direction of the force applied. There are a number of different types of abrasions: • Scratches, such as those produced by fingernails, thorns, and so on • Imprint, whereby the pattern of the weapon migh leave a characteristic abrasion on the skin • Friction, such as grazes from contact with carpet or concrete 2. Bruises are defined as an area of hemorrhage beneath the skin. Bruises are also known as hematomas or contusions. Bruising follows blunt trauma; the discoloration is caused by blood leaking from ruptured blood vessels. Bruises might also occur within a body cavity or within an organ. When commenting on bruises, exercise caution for the following reasons:

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• The current consensus view is that the age of a bruise cannot be determined with any degree of accuracy; however, this was previously thought possible and is widely taught in older textbooks. • The apparent color of the bruise can be affected by skin pigmentation and by different types of lighting. Additionally, describing color inevitably involves a subjective element. • The site of bruising is not necessarily the site of trauma. • The shape of the bruise does not necessarily reflect the shape of the weapon used. • The size of the bruise is not necessarily proportional to the amount of force delivered. Some bruises bear features that might well assist in their interpretation: • Bite marks are oval or circular bruises with a pale central area; there might also be some abrasion. In some instances, there might be a discernable dentition pattern. • Fingertip bruises are caused by the forceful application of fingertips. These usually appear as 1- to 2-cm oval or round clusters of three to four bruises. There might also be a linear or curved abrasion from contact with the fingernail. • Patterned (imprint) bruises occur when a bruise takes on the specific characteristics of the weapon used. A clothing imprint can also occur when the force is delivered through the clothing and onto the skin. • Petechial bruises are pinpoint areas of hemorrhage and are caused by the rupture of very small blood vessels. This type of bruising is usually seen in the face, scalp, or eyes after neck compression. • Trainline bruises are parallel linear bruises with a pale central area produced by forceful contact with a linear object. 3. Lacerations are defined as ragged or irregular tears or splits in the skin, subcutaneous tissues, or organs resulting from blunt trauma. The main characteristics of a lacerated wound are as follows: • Ragged, irregular, or bruised margins, which might be inverted • Intact nerves, tendons, and bands of tissue within the wound • The presence of foreign materials or hair in the wound

• The shape of the laceration might reflect the shape of the causative implement. • Incised wounds are defined as injuries produced by sharp edged objects whose length is greater than their depth. Incised wounds can be produced by a knife, razor blade, scalpel, sword, or glass fragment. It is important to distinguish between lacerations and incised wounds (also referred to as incisions or cuts), as this might assist in identifying the type of causative weapon. 4. Stab wounds are defined as incised wounds whose depth is greater than their length on the skin surface. The depth of such wounds and, in particular, the degree of trauma to deeper structures, determine the seriousness of the injury. Important points to note with respect to stab wounds include the following: • The dimensions of the wound might not be the dimensions of the blade. • The depth of stab wounds is affected by a number of factors, such as the amount of force delivered, the robustness of protective clothing, the sharpness of the tip of the blade, and tissue resistance and any movement of the victim. • The dynamics of a stabbing (unless the victim is otherwise immobilized) demand great caution when interpreting the relative positions and movements of assailant and victim. • There might be no relationship between the external dimensions of the wound and the resulting trauma to internal structures. 5. Health care providers should have a reasonable working knowledge of ballistics and gunshot wounds; however, it is quite likely that treatment of gunshot wounds will become the responsibility of a surgeon and their interpretation might require the assistance of a forensic pathologist. Unless such wounds are a regular part of your practice, you should be prepared to refer cases to more experienced practitioners for analysis. 6.9.4.14 Genito-Anal Injuries Related to Penetration Trauma to the female genitalia and anus can be caused by forceful penetration. Penetration can be by an erect or semierect male penis, by other parts of the body including the fingers and tongue, or by objects of various dimensions and characteristics. The act of penetration causes the soft tissues around the orifice to stretch. The likelihood and extent of any resultant injuries will depend on the following factors:

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• • • • •

The state of the tissues (i.e., size, lubrication, and durability) The size and characteristics of the penetrating object The amount of force used The degree of relaxation in the pelvic and perineal musculature The position of the perpetrator and angle of penetration

The posterior fourchette, the labia minora and majora, the hymen and the perianal folds are the most likely sites for injury, and abrasions, bruises, and lacerations are the most common forms of injury. The distinction between genital injury caused by consensual penetration and that caused by nonconsensual penetration is an important one. Genital injuries might occur during consensual intercourse, but visible signs of injuries (to the naked eye) are rare, and usually confined to minor abrasions to the posterior fourchette and introitus. Injury to the hymen, sufficient to cause bleeding, might occur in some females previously unaccustomed to sexual intercourse. Anal and rectal injuries are seldom seen after consensual penetration. On the other hand, not all women who allege sexual assault will have genital injury that is visible on examination performed without magnification. Indeed, in many cases, none would be expected. If a mature, sexually active woman does not resist, through fear of force or harm, and penile penetration of her vagina occurs, then it is likely that no injury will be sustained. This finding does not disprove her claim, however. Most studies indicate that less than 30 percent of premenopausal women will have genital injuries visible to the naked eye after nonconsensual penetration. This figure increases to less than 50 percent in postmenopausal women (WHO, 2003). An understanding of this issue is of fundamental importance in sexual assault medicine.

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•

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•

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• 6.9.4.15 Injury Patterns and Their Interpretation • The classification of wounds according to their main characteristics allows certain conclusions to be drawn about their causes; however, this is an area that should be approached with caution. The interpretation of injury patterns for medico-legal purposes should only be performed by practitioners with considerable experience in the field. Assaults produce a significant range of different types of injury; indeed, injuries are as varied as the assaultive actions that caused them. This diversity complicates the task of injury interpretation and, more often than not, precludes definitive conclusions. Nevertheless, some inferences about the nature and circumstances of an assault can be made from the pattern of injury in many cases. The following points should be kept in mind when assessing injury patterns in cases involving sexual violence:

•

The pattern of injuries sustained during a sexual assault can show considerable variation. This might range from a complete absence of injuries (most frequently) to fatal injuries (very rare). There are few situations in which it will be possible to state that a specific injury has been sustained in a particular way or with a particular object. In many cases it can only be concluded that the injury was caused by blunt trauma or sharp trauma. Falls during an assault or when fleeing from an assailant can produce a number of injuries. These will usually be abrasions or bruises (and occasionally lacerations) to the bony prominences of the body, with the severity of the injuries being proportional to the distance fallen. In some situations, individuals might deliberately inflict injuries on themselves. Reasons for this include an underlying psychiatric illness or secondary gain. These cases require very careful consideration before the diagnosis of selfinflicted injury is made. Information about injuries and patterns of injury is often vital in cases of sexual assault. In the event of a case proceeding to criminal prosecution, health care providers might be required to answer questions about injury patterns and to draw inferences from injury patterns about the circumstances surrounding the alleged assault, either in court or in the form of a written report. A comprehensive assessment of injuries sustained might allow comments to be made about the following: Whether the injuries were due to blunt or sharp trauma (or both) How many applications of force were required to produce the injuries, and the amount of force required to produce such injuries Whether the injuries were sustained at or about the same time The likelihood of the injuries being sustained in the manner alleged or whether there might be some alternative explanation that could also explain the injuries The possible immediate or long-term consequences of the injuries

6.9.5 FOLLOW-UP ON HEALTH CARE SERVICES AMONG VICTIMS Sexual assault has a negative impact on physical and mental health, health-related behaviors, and health service utilization. To study timely medical care’s role in preventive services, Resnick et al. (2000) obtained cross-sectional data from a larger two-year longitudinal study, the National Women’s Study (NWS). A total of 3,006 adult

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women participated in the final data collection wave of the NWS. During a structured telephone interview, women who reported a most-recent or only-rape incident during adulthood were asked about rape characteristics, reporting to authorities, medical care, and rape-related concerns. The main outcome measures were receipt and timing of medical care received after an adult rape, and factors influencing whether or not medical care was received. Of the sample, 214 (7.1 percent) had experienced a most-recent or only rape as an adult, and 56 (26.2 percent) received rape-related medical care following that incident. The final model multivariable logistic regression indicated that reporting the crime to police or other authorities and fear of STDs were significant predictors of receipt of postrape medical care. The researchers found that one in five victims reported an adult rape to police or other authorities; these women were nine times more likely to receive medical care than those who did not. Putz, Thomas, and Cowles (1996) sought to determine whether patients who receive emergency care at a sexual assault treatment center (SATC) follow suggested guidelines for prevention and treatment of associated STDs. The research consisted of a descriptive study of 26 adult victims of sexual assault who had been treated initially at an SATC. A nine-item questionnaire was designed to query participants by telephone six to eight weeks after their initial care for sexual assault. Participants were questioned about their compliance with the suggested medication regimen and follow-up medical attention. In addition, health insurance coverage information was retrieved from participants’ records to ascertain possible patterns of compliance by availability of health insurance. Participant perceptions of the nursing care received in the SATC also were elicited. Data were analyzed with frequencies and percentages, as well as qualitative categorization procedures. Twenty-six women, aged 19 to 43 years, participated in the study. Seventy-three percent reported taking all of the prophylactic medication prescribed or given to them at the SATC, whereas 50 percent had made and kept a recommended follow-up appointment with a physician. No association could be determined between compliance with the suggested follow-up protocol and the availability of health insurance. Reasons for not following suggested protocols varied greatly. Of particular importance for those who were noncompliant were the implied misunderstandings related to the need to take medications after a sexual assault. The researchers state that although concern has been expressed in the literature regarding sexual assault victims’ compliance with follow-up regimens for the prevention and treatment of STDs, the findings from this study indicate that compliance, particularly with medication protocols, might be higher than expected. However, continuing work is needed to ensure that all victims receive all recommended information regarding follow-up care during the first encounter with the nurse and that the

Forensic Nursing

rationale for follow-up care is fully understood by the patient. The researchers added that nurses who interact with victims of sexual assault are in the best position to enhance compliance with follow-up regimens by identifying victims who might be at risk of noncompliance. Holmes, Resnick, and Frampton (1998) attempted to describe medical findings and health-related concerns of sexual assault victims who returned for follow-up and to assess demographic and assault characteristics of victims who used follow-up services compared to those who did not. This study was a retrospective cohort analysis involving records from the acute sexual assault evidentiary examination and the sexual assault follow-up evaluation clinic visit. Data were extracted from the records of 389 adolescent and adult victims who reported an acute sexual assault and underwent a complete evidentiary examination between January 1, 1995, and June 30, 1997. Descriptive statistics were generated on demographic and historical information, assault characteristics, and medical and laboratory findings. There were no differences in age, race, or perpetrator factors between patients who used followup services and patients who did not return to the clinic. Similarly, there were no other assault characteristics, relationships, or physical examination findings that were associated with follow-up patterns. A total of 31 percent (n = 122) of all sexual assault victims returned for a follow-up visit. Physical complaints were reported by 42.6 percent, but 98 percent had normal findings at a general examination, and 94.8 percent had a normal result from a gynecologic examination. Pregnancy and STDs were identified through the follow-up clinic. Since the assault, 49.2 percent had been sexually active, 10 percent with multiple partners and 73.3 percent without consistent condom use. Disturbances in sleep, sexual function, and appetite were commonly reported among victims at follow-up, as were numerous assault-related fears.

6.10 GENITAL INJURIES IN SEXUAL ASSAULT VICTIMS Various studies have shown that significant physical injury from a sexual assault is rare and occurs in only 3 percent to 5 percent of rape survivors, and less than 1 percent of rape victims have been found to need hospitalization. Even minor injury is usually documented in only about one third of the reported rapes. Injuries, when they do occur, are more common in stranger rapes and rapes by someone the victim knows intimately, such as a domestic partner, rather than in date rape or acquaintance rape situations, according to studies conducted by Kilpatrick et al. (1992), Ledray (1999), Bownes, Gorman, and Saters (1991), Marchbanks, Lui, and Mercy (1990), and Tucker, Ledray, and StehleWerner (1990).

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According to Petrak and Clayton (1995), in their study of 351 rape victims, the rate of physical injury for male rape victims (40 percent) was found to be higher than for female victims (26 percent). Although 25 percent of the men and 38 percent of the women in the study sought medical care after the rape for their physical injuries, 61 percent of them told the treating physician they had been raped. The women expressed a strong preference for medical treatment and counseling by a woman. The male victims were, however, less likely to express a gender preference. A more recent study of 1,076 sexual assault victims found nongenital trauma more often than previous studies, 67 percent of the time (Riggs et al., 2000). It is also important to note that the absence of injuries does prove the lack of force or coercion and does not prove consent, according to Tucker et al. (1990). It is important that the forensic examiner is aware of the likely pattern of injuries from violence to know the appropriate questions to ask and where to look for injuries on the basis of the history given. Intentional injuries tend to be more central, and accidental injuries more toward the extremities. Especially if domestic violence is involved, injuries are most often inflicted where the victim can easily hide them. The most common injuries are broken ear drums from slapping, neck bruising from choking, punch bruising to the upper arm, and defensive posturing injuries to the outer midulnar areas of the arms. Also common are whip or cord-like injuries to the back; punch or bite injuries to the breasts and nipples; punch injuries to the abdomen, especially in pregnant women; punch and kick injuries to the lateral thighs; and facial bruising, abrasions, and lacerations (Sheridan, 1993). The literature cautions the forensic examiner against trying to date the age of a bruise by its color. Although clinicians know that in people with light skin, recent bruising is red or dark blue in color, and older bruising might be green-blue or yellow-blue, and older still bruising might be barely visible, people vary greatly in their rates of healing. Medications could affect bleeding and healing response as well. Experts suggest that the size and color should be documented (e.g., 2 cm by 3 cm, deep bluepurple bruising) without further interpretation (Ledray, 1999). It is also important to remember that it can be very difficult to even identify bruising in individuals with dark skin if alternative light sources are not available. Unfortunately, because these light sources are very expensive, most medical facilities do not have them available.

6.10.1 GENITAL TRAUMA The literature suggests that colposcopic genital examination is extremely useful to visualize and document genital abrasions, bruises, and tears, as they are often so minute they cannot be seen with the naked eye, according to Frank (1996), Ledray (2001), and Slaughter and Brown (1992).

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When the colposcope is used in the forensic examination of the sexual assault survivor it is simply used to magnify minute trauma in the genital area that is not readily visible with the naked eye, or not easily photographed. It is not being used to identify pathology. It is well documented in the legal arena that the use of the colposcope is an accepted practice in the forensic examination of adults and children (IAFN, 1996), and colposcope use for this purpose is within the scope of the SANE practice, according to Ledray (2001). The colposcope is an especially important part of the examination of children (Soderstrom, 1994). When a colposcope is used it is important to always document the magnification, the positions for examination, and a method of measurement (Soderstrom, 1994). Most research on sexual assault documents that the likelihood of genital trauma identification without the use of a colposcope to magnify the trauma is similar to that of nongenital trauma; 1 percent severe injury and 10 percent to 30 percent minor injury across studies (Ledray, 1999). Riggs et al. (2000) discovered genital trauma in 52 percent of the cases reviewed; the researchers did not indicate if a colposcope was used during the examination. With colposcopic examination, genital trauma has been identified in up to 87 percent of sexual assault cases (Slaughter & Brown, 1992). Just as with nongenital trauma, the absence of genital trauma does not indicate consent. Rape victims often fear vaginal trauma, and are concerned that their genital area has been permanently damaged. Because this is rarely true, it is helpful and reassuring to a traumatized victim to have the extent of the trauma explained to them after the forensic examination is completed (Ledray, 1999). When a video colposcope is available, it can be helpful to turn the screen so that the survivor can also view the genital area during the examination. In a study by Tintinali et al. (1985), vaginal injuries represented only 19 percent of the total injuries, and they were always accompanied by complaints of vaginal pain, discomfort, or bleeding. Geist (1988) found only 1 percent of rape victims have genital injuries so severe they require surgical repair; 75 percent of these are upper vaginal lacerations, which usually present with profuse bleeding and pain. Because the posterior fourchette is the point of greatest stress when forceful stretching occurs, and it is the point of first contact of the penis with the vagina, the resulting injury is characterized as an acute mounting injury (Slaughter & Brown, 1992). In a study that compared 311 sexual assault survivors to a group of 75 women who had consenting sexual contact, researchers identified genital trauma in 68 percent of the rape survivors, whereas only 11 percent of the women had injuries from consensual sex (Slaughter, Brown, Crowley, & Peck, 1997). Both the colposcope and anoscope have been shown to improve the identification of rectal trauma, but the colposcope might be less helpful than the anoscope. In a study (Ernst, Houry, Weiss, & Green, 2000) of 67 male

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rape victims, all examined by experienced forensic examiners, 53 percent had genital trauma identified with the naked eye alone. This number increased only slightly, 8 percent, when the colposcope was used. However, the positive findings increased a significant 32 percent when an anoscope was utilized. The combination of naked eye, colposcope, and anoscope resulted in a total positive findings in 72 percent of the cases.

6.10.2 PATTERNS OF GENITAL INJURIES IN SEXUAL ASSAULT VICTIMS AND ISSUES OF CONSENT It has been demonstrated that bodily trauma is found in many victims of sexual assault, but there are a number of medico-legal issues relating to consent defenses in these types of cases, which are discussed in chapter 13. The medical literature has generally supported the view that sexual assaults by strangers are more serious and more violent than assaults by people known to the victims. However, there are a number of forensic professionals who debate this assumption. In this section we examine the many issues related to the evidentiary examination of sexual assault victims, expectations of DNA evidence, and documentation of injuries. A look at the medical literature is in order, followed by discussion. Bowyer and Dalton (1997) report that many jurors still rely on medical evidence, in particular evidence of genital injury, to “prove” rape. They sought to ascertain the incidence of genital injury in victims of alleged rape. Conducting a retrospective review of case records of women who reported they had had been raped, the researchers found that 22 of 83 women had genital injuries; 68 of 83 women had some form of physical injury, although most of these were minor. The researchers conclude that although the study demonstrates that only a minority of women examined by specifically trained police doctors show evidence of genital injury, the absence of genital injury does not exclude rape. Jones et al. (2004) conducted a retrospective study to compare characteristics of sexual assaults by strangers and those by people known to the victims in a communitybased population of women. Study patients were consecutive female patients, 13 years or older, presenting to a sexual assault clinic during a 40-month study period. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medico-legal examinations using colposcopy with nuclear staining. Case files of 849 patients were reviewed; the age range was 13 to 82 years (mean = 22.5 years). Sexual assault by a person known to the victim accounted for 646 (76 percent) cases. The majority of these assailants (68 percent) were described as acquaintances, 139 (21 percent) were current or previous boyfriends or spouses and 33 (5 percent) involved other family members. Sexual assault by a stranger was

Forensic Nursing

more likely to occur in the home of the victim (43 percent vs. 28 percent), involve weapons or physical coercion (58 percent vs. 31 percent), and was associated with more nongenital injuries (61 percent vs. 40 percent). However, the overall frequency of ano-genital trauma (77 percent vs. 71 percent), the mean number of ano-genital injuries (2.0 vs. 2.3), and the types of genital trauma were similar in both groups of women. The researchers conclude the results demonstrated that 71 percent of the victims of acquaintance rape sustain ano-genital trauma and that these injuries can be as extensive as those caused by unknown assailants. Several studies confirm what is found most often in the literature, that sexual acts and injuries frequently—but not always—vary according to the identity of the perpetrator. Stermac, Du Mont, and Kalemba (1995) examined the characteristics of sexual assaults by strangers and those by people known to the victims in an urban communitybased population of women. All 677 women who presented to the health care center between June 1, 1991, and September 30, 1993, and for whom the victim–assailant relationship was known, were eligible for the study. The researchers found that sexual assault by a person known to the victim accounted for 456 (67.4 percent) of the assaults reported. In 344 cases the person was known more than 24 hours; 99 (28.8 percent) were current or previous boyfriends or spouses. Assailants who were strangers were more likely to assault the victim more than once, force the victim to perform fellatio, use weapons, and use physical coercion, whereas assailants who were known to the victims were more likely to assault a woman who was sleeping or drugged. Sexual assault by a known assailant was more likely to occur in the home of the victim or the assailant, whereas sexual assault by a stranger was more likely to occur outdoors or in a vehicle. Overall, the mean number of trauma sites was greater among victims assaulted by strangers than among those assaulted by people they knew. Eckert, Sugar, and Fine (2004) sought to determine whether physician gender or level of experience is associated with the prevalence of trauma documented in victims after sexual assault. All female patients 15 years or older reporting to an urban hospital with a complaint of sexual assault between January 1997 and September 1999 underwent a standardized history and physical examination by a second- or third-year resident in obstetrics and gynecology. The researchers report that the overall prevalence of genital trauma was 21 percent in the 662 patients available for analysis. The prevalence of genital trauma documented was 50 of 191 patients (26.2 percent) and 90 of 471 patients (19.1 percent), respectively, despite similar assault characteristics between the two groups. The prevalence of genital trauma documented by male examiners (105 of 499, or 21 percent) and female examiners (35 of 160, or 21.9 percent) did not differ. All

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examiners documented a similar prevalence of body trauma (52 percent). The researchers say that their study supports the hypothesis that the examiner’s experience level might influence the prevalence of genital trauma documented after a sexual assault. Adams (2001) attempted to document the frequency and types of genital injuries in adolescent women examined acutely following a sexual assault and determine any historical correlates of injury. The study consisted of retrospective chart review in an urban community hospital served by a SART. All female patients aged 14 to 19 who were referred by law enforcement for an acute sexual assault examination and were examined between May 1994 and May 1999 were included in the study. Charts of 214 female subjects (average age 16.3) were reviewed. The most common findings were posterior fourchette tear (36 percent); erythema of the labia minora, hymen, cervix, or posterior fourchette (18 percent–32 percent); and swelling of the hymen (19 percent). The researchers report that the incidence of hymenal tears in self-described virgins was higher than in nonvirgins (19 percent vs. 3 percent); however, the total number or severity of other injuries was not significantly higher in virgins. Victims reporting anal penetration had a higher frequency of anal injuries than those who denied such contact (14 of 31, or 61 percent vs. 2 of 150, or 1 percent). The researchers conclude that tears of the posterior fourchette or fossa were the most common findings (40 percent). They report that hymenal tears were uncommon, even in self-described virginal girls, and that timely examination of adolescent victims is important to document injuries. However, they state, many victims will still not have signs of bruising, abrasions, or tears. Slaughter (1997) emphasizes that conventional rape examination protocols have been poor in yielding genital findings (10 percent–30 percent typically). In their study, the researchers looked at a revised protocol employing colposcopy to perform genital examinations of victims and to document findings. Physical examinations were performed on rape victims seen by San Luis Obispo County’s Suspected Abuse Response Team between 1985 and 1990. Of 131 patients seen within 48 hours who experienced penile penetration, 114 (87 percent) had positive findings. Colposcopic magnification allowed examiners to characterize these findings as acute mounting injuries, typically seen at 3, 6, and 9 o’clock on the posterior fourchette and consisting chiefly of lacerations, ecchymosis, and swelling. The researchers conclude that an examination protocol that includes colposcopy might be the most reliable means to document and characterize genital findings in rape victims and to evaluate whether findings can be linked to a reported sexual assault. Reznic, Nachman, and Hiss (2004) state that in most cases of sexual assault, even following long-term abuse, genital and extragenital injuries might be very scarce or literally not found. Although the forensic experts custom-

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arily illustrate to the court that the absence of physical trauma does not rule out that the assault took place, more substantial medical evidence can be helpful in pursuing a conviction. Reznic and colleagues examined three cases at the National Center of Forensic Medicine in Tel-Aviv in which information obtained during questioning of the victims concerning genital pathology of the assailant was later verified through examination of the suspects. The researchers say that such data could provide key evidence to get an indictment when the assault is perpetrated by a stranger or a person who should not have an intimate relationship with the victim. Therefore, the researchers say, acquiring information from the victim concerning any pathology of the assailant’s genitalia should be part of the routine questionnaire form for victims of suspected sexual assault or abuse, as findings of this sort might become paramount in conviction of perpetrators. Biggs, Stermac, and Divinisky (1998) say that the literature on sexual assault has not directly addressed the question of genital injuries in women without prior sexual intercourse experience. Given the paucity of research and the current importance of physical evidence in the criminal justice system, the researchers say their study was designed to document the type and site of genital injuries from sexual assault in women without and with prior sexual intercourse experience. The charts of 132 women who had been sexually assaulted and had sought medical treatment at the Sexual Assault Care Centre at the Women’s College Hospital in Toronto within 10 days after the assault were reviewed. Half (66) of the women reported that, at the time of the assault, they had no prior sexual intercourse experience. The rape kit in each patient’s file was reviewed to ascertain the type and location of genital injuries. Types of injuries were classified into three categories (nonperforating soft-tissue injuries, lacerations, or current bleeding) and locations into six categories (labia majora and minora, posterior fourchette and introitus, hymen, vagina, cervix, and anus). The researchers say that significantly more women without than with prior sexual intercourse experience had visible genital injuries (65.2 percent vs. 25.8 percent). However, of the women without prior experience, only 9.1 percent had hymenal perforation. Analyses of the data for only women with genital injuries indicated no difference between those without and those with prior sexual intercourse experience in the overall mean number of injured sites (1.65 and 1.47, respectively) or in the mean number of sites with nonperforating soft-tissue injuries (0.349 and 0.706), lacerations (0.953 and 0.471), and bleeding (0.279 and 0.294). The researchers say the results suggest that genital injuries are more common in women without prior sexual intercourse experience but that substantial proportions of all women, regardless of their prior sexual experience at the time of assault, will not have visible genital injuries. They add that ED staff and members of the criminal justice system

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should be aware of the variable presentation of genital trauma related to sexual assault in women with and without prior sexual intercourse experience. Jones et al. (2004) set out to determine the incidence of toluidine-blue positive findings after speculum examination of sexual assault victims. The researchers performed a prospective before and after study of 27 female patients presenting after sexual assault to a free-standing nurse examiner clinic. Before the insertion of a speculum, a 1 percent aqueous solution of toluidine blue was applied to the posterior fourchette and photographs were taken using colposcopy with digital imaging (16x magnification). After the forensic examination was completed, dye was reapplied. Photographs taken before and after speculum examination were reviewed by three emergency medicine physicians for superficial lacerations or abrasions. Before speculum examination, genital injuries from sexual assault were documented in 67 percent of the patients (mean number of genital injuries = 1.4). After speculum examination, one patient (3.7 percent) demonstrated a new genital injury, an abrasion to the labia. The researchers say that until further studies are performed, use of a speculum should be delayed until after toluidine dye application. Rossman et al. (2004) assert that clinicians might not perform a medico-legal examination in cases in which a sexual assault was attempted but no penile–vaginal contact occurred. The researchers conducted a retrospective study to document the frequency and type of genital injuries in women in whom forced digital penetration was the only reported type of assault. Study patients were consecutive female patients presenting to an urban sexual assault clinic during a three-year study period. The clinic is associated with a university-affiliated urban hospital and is staffed by registered nurses trained to perform forensic examinations using colposcopy with nuclear staining. Case files of 941 patients were reviewed; 6 percent (53) reported only digital–vaginal contact. Genital injuries were documented in 81 percent of the patients (mean number of genital injuries = 2.4). Fifty-six percent of the injuries occurred at four sites: fossa navicularis, labia minora, cervix, and posterior fourchette. The most common type of injury was erythema (34 percent) followed by superficial tears (29 percent) and abrasions (21 percent). The researchers say that colposcopy with nuclear staining was useful in detecting these injuries and can provide valuable legal information in sexual assault victims reporting only digital–vaginal penetration. Jones and Dunnuck et al. (2003) conducted a study to determine the usefulness of the Foley catheter balloon technique for visualizing injuries of the estrogenized hymen in adolescent sexual assault victims compared with supine labial traction. A prospective clinical trial of 20 adolescent (age 13–16) victims of sexual assault was held at a freestanding nurse examiner clinic and was conducted over a four-month study period. The clinic, affiliated with an

Forensic Nursing

emergency medicine residency program, was staffed by registered nurses who have been specially trained to perform medico-legal examinations using colposcopy with digital imaging. The Foley catheter technique uses an inflated balloon in the distal vaginal vault to expand the estrogenized hymen to its full capacity so that the edge can be readily visualized for signs of trauma. The Foley technique was compared with gross inspection, using supine labial traction, to photo-document hymenal abnormalities. Photographs of the hymen were obtained using the labial traction technique and then the Foley technique. Three emergency physicians independently examined each pair of photographs with high interrater agreement for the presence of injury. Twenty adolescent sexual assault victims volunteered for the study; the average age was 14.8 years. Gross inspection of the hymen using supine labial traction identified hymenal injuries in three patients (15 percent). Use of the Foley catheter balloon technique allowed identification of hymenal abnormalities in nine additional cases (60 percent). The common injuries to the hymen included lacerations (30 percent), followed by ecchymosis and abrasions. One patient (5 percent) voiced discomfort (mild pressure sensation) during inflation of the balloon. The researchers concluded that the Foley catheter balloon technique is a simple method allowing improved photo-documentation of hymenal trauma in adolescent sexual assault victims compared with supine labial traction. Jones and Rossman et al. (2003) sought to compare the characteristics of sexual assault in pubertal girls younger than 18 and adults in a community-based population of women presenting to an urban sexual assault clinic. The researchers evaluated consecutive female patients presenting to a sexual assault clinic during a threeyear study period. The clinic was associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medico-legal examinations using colposcopy with nuclear staining. A total of 766 cases were identified: 43 percent of the victims were 13 to 17 years old (mean = 15 years old), and 57 percent were older than 17 years old (mean = 30.8 years old). Adolescents were more likely to be assaulted by an acquaintance or relative (84 percent vs. 50 percent) and to delay medical evaluation (17 hours vs. 12 hours) than were older women. Adolescent sexual assault was less likely to involve weapons or physical coercion (29 percent vs. 57 percent) and was associated with fewer nongenital injuries (33 percent vs. 55 percent). Adolescents had a greater frequency of ano-genital injuries (83 percent vs. 64 percent), however, compared with older women. Common sites of injury in adolescents were posterior, including the fossa navicularis, hymen, fourchette, and labia minora. The injuries showed consistent topologic features, varying with the site and nature of tissue. Adult victims of sexual assault had a less consistent pattern of ano-genital injuries with fewer hymenal injuries,

Sexual Assault

greater injury to the perianal area, and widespread erythema. The researchers concluded that the epidemiology of sexual trauma and the pattern of ano-genital trauma in this age group are unique and might pose special challenges to emergency health care providers. Sugar, Fine, and Eckert (2004) sought to determine characteristics associated with physical injury in female sexual assault victims. All females who were 15 years or older presenting after sexual assault to an urban ED during a 34-month period underwent standardized evaluation. Of 819 women, 52 percent had general body and 20 percent had genital-anal trauma; 41 percent were without injury. General body trauma was independently associated with being hit or kicked, attempted strangulation, oral or anal penetration, and stranger assault. Genital-anal injury was more frequent in victims younger than 20 and older than 49 years, in virgins, and in those examined within 24 hours and after anal assault. Jones, Dunnick, and Rossman (2003) compared the types and locations of ano-genital injuries occurring in adolescent females (13–17 years old) after consensual and nonconsensual sexual intercourse. The researchers conducted a retrospective, matched case-control study to assess ano-genital injuries in female adolescents presenting to a free-standing nurse examiner clinic during a fouryear study period. Adolescents were selected for inclusion in the study if they reported consensual sexual intercourse and agreed to a medico-legal examination. Control subjects were victims of alleged sexual assault or nonconsensual sexual intercourse matched to cases by age and prior sexual intercourse experience. Genital trauma was documented using colposcopy with nuclear staining and digital photography. Fifty-one cases of consensual sexual intercourse were identified; the age range was 13 to 17 years (mean = 15.1 years). Overall, 49 percent (25 of 51) of consensual sexual intercourse subjects reported no prior sexual intercourse experience. Consensual and nonconsensual sexual intercourse were comparable in terms of race, time to physical examination, alcohol use, and frequency of genital injuries (73 percent vs. 85 percent). The mean number of documented ano-genital injuries in consensual sexual intercourse subjects was 1.9 (+/– 1.5). These injuries commonly involved the hymen, fossa navicularis, and posterior fourchette. Consensual sexual intercourse subjects had a greater number of ano-genital injuries (2.6 +/– 2.0), typically involving the fossa navicularis, labia minora, and hymen. The most common type of injury in both groups was lacerations (39 percent vs. 41 percent); however, nonconsensual sexual intercourse subjects had a greater incidence of ano-genital abrasions, ecchymosis, and edema. Mancino et al. (2003) assert that victims of sexual assault require appropriate care, follow-up, and information regarding their legal rights. Clinicians are faced with the challenging responsibility of identifying victims and

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providing effective intervention and preventive counseling. They add that the most pressing medical task is to confirm the assault and to undertake correct documentation and exhibition of biological traces. They explain that performing colposcopy and vulvovaginoscopy does not allow clinicians to diagnose a sexual assault trauma, but it can help them to identify those microscopic lesions (due to the enhanced visualization and the higher resolution under which the genital areas are examined) that might not be seen during a normal clinical examination. The colposcopic and vulvovaginoscopic examination starts from the vulvar region looking for superficial lacerations and ecchymosis; the labia majora and minora are examined scrupulously, then the posterior forchette, the perineum, and the hymen, where it is possible to report micro-ulcerations, contusions, and even possible scars due to a precedent defloration. Recent advances in clinical forensic medicine show that trained examiners using colposcopy obtain evidence of genital trauma in 87 percent to 92 percent of rape victims. The researchers emphasize that colposcopy and vulvovaginoscopy must be performed within 48 hours of the sexual assault, because most of the lesions heal rapidly. Colposcopy and vulvovaginoscopy might be seen as a stressful invasion of a woman who is already vulnerable and at risk of RTS. Prior information about colposcopy might reduce the level of anxiety experienced by many women undergoing this procedure. The researchers say that incorporating colposcopy and vulvovaginoscopy into the routine assessment of sexual assault victims could be a valid way of identifying genital injuries, and the medical report will be more detailed and precise. Sachs and Chu (2002) say that legal decisions in sexual assault cases often hinge on the presence or absence of genitor-rectal injury but add that the forensic literature does not explain why some victims sustain genitor-rectal injury and others do not. Their study attempted to explore possible predictors of genitor-rectal injury in adult female sexual assault victims. They conducted a retrospective study of cases, extracting data describing consecutive female sexual assault victims who met inclusion criteria between July 1995 and July 1998. Exclusion criteria included male sex, lack of estrogen in females, consensual intercourse within the previous 72 hours, and lack of penetration during the assault. The researchers explored associations between genitor-rectal injury and seven demographic variables, nine assault characteristics, and the time between assault and exam or postcoital interval (PCI). Five hundred forty-eight sexual assault victims were seen during the study time period; 209 of these met the inclusion criteria. Logistic regression controlling for important covariates showed an increased risk of genitor-rectal injury with a PCI of less than 24 hours, physical and verbal resistance, rectal penetration, and greater than a high school education.

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Adams, Girardin, and Faugno (2000) report that adolescent females are the most frequent victims of sexual assault, but studies to document the presence of genital findings in patients examined within 72 hours, using magnification and dye, have not been published. Their study was designed to document the frequency and types of genital injuries in adolescent women following acute sexual assault, using chart and photograph review. The most common findings recorded by the nurse examiner were posterior fourchette tear (36 percent); erythema of the labia minora, hymen, cervix, or posterior fourchette (18 percent–32 percent); and swelling of the hymen (19 percent). Uptake of toluidine dye was noted in 66 percent of patients in whom it was applied. Overall, 21 percent of patients were found to have no findings, and 40 percent had tears of the posterior fourchette or fossa. Time to examination was highly correlated with the degree of injury noted. The incidence of hymenal tears in selfdescribed virgins was higher than in nonvirgins (19 percent vs. 3 percent), however the total number or severity of other injuries was not significantly higher in virgins. Reported anal penetration was associated with a high frequency of anal bruising, abrasions, or tears (14 of 23, or 61 percent), and only two of 150 victims who denied anal penetration had tears (1 percent). Victims who reported multiple physical symptoms such as pain, nausea, or vomiting were significantly more likely to be older and to have an increased number of nongenital injuries such as bruising, abrasions, and bite marks. A higher number of nongenital injuries was also correlated with a higher number of total genital injuries. Finally, Lincoln (2001) surveyed the available literature on genital injury to facilitate an understanding of its significance in relation to sexual offense trials, and reported that wide variation exists in research objectives, study populations, and methodology, hindering interpretation considerably. Lincoln says that the most valuable research in this field identifies the range of normal genital findings and those associated with consensual sexual intercourse, to enable interpretation of genital findings in sexual assault victims, but few studies of this nature exist. Lincoln acknowledges that difficulties arise when examining doctors are not experienced in the genital examination of those other than sexual assault victims, limiting their ability to draw conclusions about genital injury if it is detected. If the methods of genital examination employed are not the same as those used to examine a wide range of nonsexual assault victims, comparison and thus valuable interpretation is further limited. Lincoln’s review of the literature finds that the most appropriate genital examinations and the most legally valuable as far as interpretation is concerned are done macroscopically by doctors with considerable experience in the examination of normal, diseased, and traumatized genitalia, and a sound knowledge of the principles of injury interpretation.

Forensic Nursing

Lincoln says that a deficiency exists in the literature in relation to macroscopic genital examination findings in consensually sexually active women who have been examined by forensically trained doctors. This deficiency must be addressed before the medico-legal significance of genital injury relating to sexual assault can be accurately interpreted, and before any decision is made to incorporate colposcopy or staining techniques into the routine assessment of sexual assault victims. One of the more definitive studies of genital injury in sexual assault victims was conducted by Slaughter et al. (1997), who emphasize that the most important objective of the medico-legal examination of sexual assault vitims is “to provide competent evidence collection to assist in the investigation of the incident.” The researchers say that recent advances in clinical forensic medicine have allowed forensic examiners using colposcopy to identify and obtain evidence of genital trauma in 87 percent to 92 percent of rape victims within 48 hours. They add that this is a significant improvement over protocols that have traditionally relied on gross visualization or toluidine blue dye enhancement. Because there has been little material published about the location, extent, and types of injury seen in sexual assault victims, Slaughter et al. emphasized the importance of discussing and comparing the findings of rape victims with the genital findings in women having consensual intercourse. The researchers observe, “Previous studies using nuclear staining have shown that the prevalence of genital injury in women who complain of rape is greater than that seen in women without this history,” but add that the use of colposcopic magnification might provide additional findings. The researchers studied the locations and types of genital injury seen in female assault victims compared with women engaging in consensual sex. They performed sexual assault examinations (using colposcopy to evaluate ano-genital trauma) on 311 rape victims seen by San Luis Obispo County (California)’s Suspected Abuse Response Team between 1985 and 1993 and contemporaneously on 75 women after consensual sexual intercourse. The researchers assessed how six factors—time from complaint to examination, relationship of victim and assailant, age of victim, type of sex act reported, presence of nongenital trauma, and history of nonsensual sexual intercourse—related to physical findings in the victims. The researchers found that among the 311 assault victims, 213 (68 percent) had ano-genital trauma; among the 178 (57 percent) patients with nongenital trauma, 132 (74 percent) also had genital injury. Two patients had required hospitalization, one for head trauma, and the other for vaginal laceration. The researchers reported that penile penetration was the most common reported type of assault associated with genital injury, and the absence of penile penetration of the vagina accounted for the largest proportion of victims with normal findings. It was discovered that 41 percent of women described their assailant as an

Sexual Assault

intimate partner; within this group, 49 percent had anogenital trauma and 56 percent had nongenital injury. The researchers observe, “The proportion with ano-genital trauma was significantly higher for those women without a relationship to the offender than for those with such a relationship.” One-hundred sixty-two (76 percent) of the women had an average of 3.1 sites of injury; comparatively, eight (11 percent) consenting women had just single-site trauma. Two hundred (94 percent) victims had trauma at one or more of four locations, as follows: posterior fourchette, labia minora, hymen, and fossa navicularis. The researchers report that trauma types varied by site; tears appeared most often on the posterior fourchette and fossa, abrasions appeared on the labia, and ecchymosis was seen on the hymen. Fifty-five patients reported anal contact, with six victims reporting it as the only sexual act of the assault. Hymenal or vaginal laceration was found in five victims, and vaginal laceration alone was found in nine cases. The researchers found that hymenal, vaginal, and combined tears were all associated with penile penetration with the exception of one case of penetration with a foreign object, and all patients reported vaginal bleeding. The researchers focused specifically on cases of penile penetration, as it is the most common type of assault associated with vaginal injury. Approximately 82 patients (38 percent) returned for follow-up examination within an average of 25 days after the assault. The researchers reported that all injury had resolved in 71 cases (87 percent). The researchers reported that hymenal tears and tears of the area of the fossa navicularis did not reunite, and no scarring was observed. They added that five women exhibited localized areas of hypervascularity or pigmentation that were initially viewed as trauma, necessitating an addendum to amend the first evaluation. In the consensual intercourse group, 75 women were seen within 24 hours after intercourse; trauma was noted in eight consenting women (11 percent) and was limited to one site. The injury had resolved by the time of a followup examination. In follow-up visits within 48 hours, six women had hypervascularity as a persistent finding. The researchers write, “Our findings show that genital trauma is common in victims of sexual assault, occurring in 68 percent of all patients, and is more commonly observed than injury associated with complaints of sodomy (56 percent). Moreover, our data confirm prior information showing that the prevalence of genital injury in rape is greater than in those women engaging in consensual intercourse.” They add that the severity and extent of trauma in rape victims appear to differ from changes after consensual intercourse. The researchers also conclude that injuries showing consistent topologic features provide evidence that the most significant cause of genital trauma in rape victims occurs as entry injury, with insertion or attempts at insertion by a penis or other foreign object into the vagina. They add that the hymen was not the most

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common site of injury in either adults or adolescents, confirming the vulnerability of the posterior fourchette in sexual assult. Significantly, the researchers note, the average number of injury sites did not correspond to the time interval between the assault and the examination, suggesting that time could enhance the visibility of some lesions and injuries, or that the severity of the injury might cause victims to delay reporting. The researchers emphasize, “Prompt forensic assessment of all victims of sex crimes is important. Delayed reporting continues to occur with a substantial frequency . . . Nearly 50 percent of victims seen for examination at or after 72 hours had positive genital findings. Therefore, law enforcement should consider obtaining a forensic evaluation, even though trace evidence may have dissipated.” They add, “Evidence of trauma has already been shown to be significantly associated with successful prosecution.” Slaughter et al. (1997) explain that ultimately, forensic examiners must be able to analyze and explain genital findings to the court. They conclude, “Now that we have more descriptive information about genital trauma in rape victims and comparative data from women engaging in consensual sex, we can better understand the mechanism of injury seen in rape victims and begin to develop taxonomy of genital trauma that is based on degree and type of injury, establishing a more reliable basis for forensic analysis.” They alluded to injury to the cervix, predominantly ecchymosis, which was “difficult to see without careful inspection and magnification,” and which might have been overlooked previously. Slaughter and Brown (1991) sought to provide corroborative physical data from rape victims to refute previous studies showing positive physical findings in only 10 percent to 30 percent of rape cases. They write, “This dismal result has prompted some authors to suggest that the performance of a genital examination be reserved for those who complain of pain or have a history of undergoing instrumentation.” Slaughter and Brown reported on two cases of cervical findings through the use of colposcopy magnification; in one case, a 17year-old woman was digitally penetrated, and in the other, a 30-year-old woman had been assaulted by what the victim described as something that felt like a knife in her vagina. An examination of the 17-year-old was conducted five days later; punctuated areas of hemorrhage were seen on the hymen at the 5- and 7-o’clock locations while the patient was in a supine position. Cervical examination revealed fine linear abrasions just below the cervical os. The 30-year-old was examined two hours after the assault. Genital examination revealed blood at the introitus, and a linear laceration was noted on the right in the vaginal barrel. The cervix showed several punctuate and linear lacerations. The researchers noted that armed with advanced technology afforded by the colposcope, they were able to detect and photograph trauma to the victim’s cervix, a type of injury that had not been previously

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reported. They write, “These two cases illustrate how trauma can be reliably documented via colposcopic magnification; in both, the pattern of injury is consistent with blunt-force or penile penetration.” They add that documentation of the healing process—which was observed to be within days or a few weeks in both victims—is an important part of forensic assessment. They explain, “First, it links the traumatic event to the injuries observed, establishing a reliable time frame associated with injury. Second, documentation of the victim’s normal anatomy in the follow-up examination effectively establishes her as her own control against which the court can evaluate the nature, extent and cause of the injury.” The researchers emphasize that this is critical when the body parts that are injured are not ones that can be seen; these injuries are easy to dismiss as trivial from a purely medical standpoint, but from a medico-legal standpoint, the researchers say, the information gathered from the colposcopic examination is significant. The information supports vaginal penetration, which is fundamental to a charge of rape, and it can also substantiate penetration with a foreign object, which is a separate crime. By the early 1990s, Slaughter and Brown (1992) had used colposcopy to establish some of the first physical findings in rape victims. They write, “The difficulty of establishing physical findings in rape victims has been an accepted limitation in the medical and legal process that addresses sexual assault.” They add that while a physical examination is a crucial part of patient management and that the findings can corroborate rape, conventional protocols have yielded an unacceptably low rate of positive findings. They also say that somewhat better results had been found when using toluidine blue dye to evaluate patients who had experienced penile penetration who are seen within 48 hours of the assault. In their study, Slaughter and Brown performed physical examinations on rape victims seen by the San Louis Obispo County’s SART between 1985 and 1990. Of 131 patients examined within 48 hours and who experienced penile penetration, 114 (87 percent) had positive findings. Using colposcopic examination, the researchers were able to characrterize these findings as acute mounting injuries, typically seen at 3, 6, and 9 o’clock on the posterior fourchette and consisting mainly of lacerations, swelling, and ecchymosis. Although toluidine blue dye has been helpful in visualization of gential injuries, forensic examiners have noted some limitations. As a nuclear stain, toluidine blue has been used to bind with and to detect lacerations that expose the deeper dermis. Various researchers, according to Slaughter and Brown, have been able to demonstrate an increase in detection of vaginal lacerations from 1 in 24 rape victims to 14 in 24 following the application of toluidine blue. Slaughter and Brown point out, however, that the dye will not be taken up in injuries that are superficial or are beginning to re-epithelialize. They note, “In our

Forensic Nursing

series toluidine blue did not define trauma not already seen with the colposcope. However, anticipating the need for a clear pictorial presentation of the findings in court, toluidine blue is useful to highlight injuries that a lay audience would find difficult to appreciate.”

6.10.3 POSTMORTEM GENITAL EXAMINATIONS The investigation of sexual homicide has traditionally not been within the nurse’s purview; however, several FNEs have not only been practicing in the field, but have published what little nursing-driven research exists in this field. Skilled in the nuances of sexual assault and in come cases, in tandem with medico-legal death investigation, the FNE is uniquely qualified to assist forensic pathologists, law enforcement agencies, and prosecutors in these complex cases. Having established their expertise in the examination of living forensic patients, FNEs are extremely capable of providing postmortem examinations in suspected cases of sexual homicide through the use of advanced colposcopic technology and progressive evidentiary examination protocol. FNEs are adept at recognizing and interpreting postmortem changes in the body, which facilitates the identification of normal versus abnormal postmortem changes that point to potential criminal acts. One examiner who has made significant strides in postmortem genital examination research is Sharon Crowley, MN, RN, a forensic clinical nurse specialist in Santa Cruz, California, who has consistently presented her research to the AAFS and has been published in the prestigious Journal of Forensic Science. Initiated in 1995, Crowley’s work has focused on the colposcopic magnification of genital injuries in decedent victims of sexual assault. She acknowledges work by Slaughter and others, as well as her own findings that have established the common genital findings of living sexual assault victims, facilitated by the use of colposcopic magnification. However, Crowley was interested in the genital findings of decedents, and knew there was a paucity of information on this subject in the medical literature. Crowley, author of Sexual Assault: The Medical-Legal Examination (1999), developed a “Sequential Methodology for the Examination of Sexual Homicide Victims” as a response to the need for a systematic examination method of decedents. Her research included a study of 18 decedents whose deaths were determined to be accidental, natural, and suicide. Using a mobile system of colposcopy that she invented, Crowley evaluated the ano-genital regions of the victims in collaboration with a forensic pathologist. The decedents ranged in age from 6 to 72, with an average age of almost 49 years. The postmortem interval ranged from less than 24 hours to more than a few days, and all bodies were in a state of active decay. Crowley examined 11 anatomical sites: labia majora, labia minora, periutereal

Sexual Assault

area, posterior fourchette, fossa navicularis, hymen, vagina, cervix, perineum, anus, and rectum. This kind of work, as well as Crowley’s mobile colposcopy system, was the subject of an article in the November 2004 issue of the Journal of Forensic Science, “A Mobile System for Postmortem Genital Examination With Colposcopy: SART-to-Go.” Crowley devised her mobile system after identifying the need to bring examiner services to the decedent in a jurisdiction that lacked a centrally located morgue. During Crowley’s initial rapehomicide examinations, only gross visualization methods were available, and she knew there had to be a better way to scrutinize the ano-genital tissues at various postmortem intervals. Crowley says this kind of examination is crucial in sexual homicide cases, where the offender’s sexual motivation for homicide is based on the accurate assessment of information regarding the victim, the crime scene, forensic reports, and the nature of the behavioral exchange between the victim and the offender. She says sexually motivated offenders can be classified as organized, disorganized, mixed, and sadistic, with each characterization affecting the manner in which the sexual homicide was committed. This classification system helps examiners, investigators, and criminal profilers determine a course of forensic investigation and examination. In her “Sequential Methodology for the Examination of Sexual Homicide Victims,” Crowley (2005) outlines an approach that “incorporates all facets of the examination process” and “helps to ensure that the myriad aspects of the entire evaluation will be completed.” She explains that a standardized, methodical approach minimizes omissions and avoids errors, which is particularly important in jurisdictions with varying protocols. Prior to the start of the autopsy, Crowley recommends that individual roles and responsibilities of each forensic team member should be clarified in terms of evidence collection, photography, and documentation of nongenital trauma. Crowley also advises, “If possible, conduct the genital examination and collect ano-genital specimens prior to the general autopsy. This may be done after the forensic pathologist has done a preliminary overview of the body and noted gross features such as clothing. This allows prompt collection of biological specimens and avoids obscuring the genital area by leakage of body fluids through the vaginal opening.” The next step is setting up a work area with all the necessary equipment, including a still-sealed rape evidence kit to facilitate evidence collection during the postmortem examination. All pertinent case data should be documented next, including demographic data, disposition of the body at the crime scene, victim’s medical history, and results of the general physical examination of the decedent. Evidence is then collected from the body, observing proper forensic protocol.

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Postmortem genital examination, as described by Crowley, involves a number of body sites and collection techniques, including the following: • • • • • • • • • • • •

Oral swabs Vaginal swabs Vaginal lavage Cervix swabs Penile swabs External genital swabs Anal swabs Swabs of dried secretions Collection of debris Fingernail scrapings Collection of encrusted stains Collection of condoms

Crowley emphasizes that the examination creates the framework of all medico-legal reports, and the examiner must ensure its completeness and accuracy. She writes, “In the summary of findings for the postmortem anogenital evaluation, describe the nature and pattern/location of any injuries. Distinguish multiple vs. single sites of injury. Describe the overall appearance and integrity of the anogenital tissues. This may include concomitant postmortem tissue changes, e.g., lividity, dilatation, skin slippage, or mucosal shedding.”

6.10.4 UP CLOSE CROWLEY

AND

CLINICAL WITH SHARON

Crowley says her postmortem genital examination research had humble beginnings in her professional dealings with law enforcement while she was working as a nurse in San Luis Obispo. In fact, she says, laughing, “I blame the cops for getting me into this; I was quite fine in the world of the living.” She explains that one day, “A detective called me and explained that he had a female homicide victim whom he wanted me to examine to determine if she had also been sexually assaulted,” Crowley recalls: There was a tradition of doing this kind of examination where I worked, so it wasn’t the first time. But when I started to do the examination, something just clicked and I thought to myself, “This is a different world altogether.” I realized that it isn’t the same as with a living forensic patient, and I also realized, as I began to study the subject more, that as little research as we had on living victims, there was nothing on dead victims. The more I dug, the more I realized this and by the time I did my second and third cases, I realized, “OK, this is going to be a habit. I need to get some kind of a system going.” Because every time I did a post-mortem examination, it felt like it was for the first time; I needed a standardized system.

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Before she developed her methodology, Crowley quips, “I flew by the seat of my pants.” Now, to know Crowley is to understand that she takes nothing related to her job lightly, but she recognized the utter absence of guidance in the medical literature for these kinds of cases: I did what I thought worked, and as I really started studying it, I pulled from the research conducted by the FBI and the world of criminal profiling. When I got involved with homicides, I developed a burning curiosity. I wondered if all of this stuff about different kinds of rapists tied in any way to what we, as nurses and pathologists, see when we examine decedents. I started researching all the different aspects of sexual homicide cases, from the profiling of various kinds of sexual murders, and scrutinizing methods of examining living sexual assault victims in order to better perform evidence collection and documentation. After all, you are now dealing with a victim who can’t give a history, at least not verbally—the body will have to tell the tale. But you have huge sections of information for which we rely on living victims that are now blank. There is no one to give you instant answers to your questions. Once I understood the parameters of working with decedents, I started assembling the equipment I needed to do post-mortem cases.

Because Crowley tended to a lot of cases in jurisdictions that lacked a central morgue, Crowley then developed her mobile system, which she calls SART-to-Go. She explains: I did a lot of fast talking and got a company to loan me equipment. It took at least a year or more of trial and error in setting up the equipment in the back of my truck, to see what worked and what didn’t. I put together the methodology based on what worked and what I thought would work in a variety of different areas and examination settings. When I started in San Luis Obispo there was no central morgue; examinations were done at different mortuaries, which was a huge challenge logistically. Yet that’s the way it is done in many rural areas, or else you go to a fancy, highly scientific morgue, which is real convenient. So I challenged myself to come up with a system that would work no matter where the examination was done.

Crowley knew that the next step, once she had perfected her methodology, was to get this system in front of her forensic peers and colleagues: As I wrote each protocol, because it was such a new field, I wanted to get scientific peer review. So I presented my ideas every year; I would write another abstract or a case study, and present it wherever I could, at AAFS meeting or some other professional conference. At AAFS I presented my first rape homicide, which happened in 1994. I wrote it up and collaborated with a criminal investigator/profiler on that case because we’d also examined the suspect. That’s when I was first thinking along the lines

Forensic Nursing

of, what fits into what I see anatomically, and the kind of perpetrator who would do this crime. In 2000, I wondered if they’d let a nurse chair and conduct a workshop on postmortem genital examination, so I asked, and ended up doing a four-hour workshop which I also chaired.

At that time, Crowley connected with an epidemiologist who helped her create a database to collect data derived from each case, including the case identification number assigned to it, and the victim’s age, ethnicity, race; the date of the examination; the postmortem interval; the cause of death; medical history; gross nongenital trauma; and examination protocol performed. Crowley knew it was important to establish a framework to support the systematic collection and analysis of evidence and data, and to further classify the postmortem genital findings. “I had envisioned a database that would one day allow me to pull up whatever data I needed about a particular victim,” Crowley explains: Say you have a Caucasian woman with such-and-such injuries sustained in a rape-homicide at four days postmortem, and I wanted to be able to compare this victim with other victims in other age ranges, races, and genital injuries. I wanted a database that could refute the old argument based in comparing findings of living patients and decedents in court. I wanted to have something to compare apples to apples instead of apples to oranges. So the epidemiologist helped me create the mechanics of a database; I told him what variables I wanted in it and he helped me with the framework. Then I got Brian Peterson, MD, who was the pathologist that I had been working with, on board with this project. I was also interested in the work by the forensic odontologist, Bob Barsley, at Louisiana State University. He was totally supportive of my work. This kind of collaboration illustrates the fact that if I am going to publish my research findings, I need to consult professionals who can tell me if I’m on track or not. Having forensic colleagues’ buy-in strengthens the project, and it tells them, “Hey, nurses can do this.”

Crowley says that at every step of the way in her quest to publish her research, she involved her peers and colleagues in the forensic community, and kept her work in the full scrutiny of the AAFS membership: I knew it was a hot topic in a new field, and I wanted to give these scientists every reason to look over my work and comment on it. And when you start gaining acceptance, then you introduce the concept of nurses conducting this kind of research. It’s a lengthy process of gaining credibility and earning their stamp of approval. I think that’s the battle we have to fight as nurses. But once you get the support you need, it’s awesome. Unless you screw it up, you’ve got them.

In February 2003, Crowley, a fellow of the AAFS, was honored by the Academy with its prestigious General Sec-

Sexual Assault

tion Achievement Award. So how did this public health nurse and STD coordinator for the Santa Cruz, California Department of Health, pediatric SART examiner, and FCNS for Santa Clara Valley Medical Center’s Center for Child Protection in San Jose, California, end up where she is now? She says it’s been a long, glorious road full of twists and turns. As a young nurse with a freshly minted bachelor’s degree, Crowley worked in med-surg, coronary care, and the ICU for a year before deciding to pursue a master’s degree. She comments: At the time, being a clinical nurse specialist was a very new thing, but so was the nurse practitioner program. It was very new to try to have a master’s of education degree in nursing and yet not be a researcher, an educator, or an administrator. I wanted to be clinically focused. So I went the CNS route, and at the time, my love and great passion in life was cardiovascular care. While I was in grad school I worked in open heart surgery. After graduating I got a job at USC Medical Center, but they didn’t know what to do with me; they didn’t have a position for someone with a master’s degree, but they were desperate for nurses to work in their special-care units. They resembled mini ICUs; new nursing grads were placed into these units alone with five patients for 12-hour shifts. They needed someone to show these new nurses how to provide nursing care in a hands-on training environment. I devised my own role, and that’s the way it’s been for the last 30 years . . . basically creating my job as I go.

Crowley explains that when she left grad school, “I couldn’t find the job I really wanted, but I found it 30 years later. Jobs tend to follow me rather than be available at the time I really want them,” she says, laughing. “So I’ll be 80 when I find the job I really want now!” she kids. Crowley’s résumé encompasses nursing experience in nearly every setting and community, but when she was ready to take a breather, she moved to northern California to get married, have kids, and settle down. “I even explored the possibility of becoming a chiropractor, because I was getting burned out on nursing,” she recalls. “Things started evolving in nursing, and in the late 1980s I got into forensic nursing. And everything changed.” Crowley says she was asked to join a child abuse prevention council in Santa Cruz, which she did. “I did that for about a year; all along, the nurse examiner program had been in operation since 1986, the first nurse examiner program in California. I joined it in 1988 and went through the SART training.” She explains: I’ve never been one to sit down and put all the pieces together before I did anything. I’ve sort of leaped in and went for it when it felt right to do so. The pieces of the puzzle always seemed to fall into place afterward. I recognized the need for forensic nursing, and it seemed exciting; the time was certainly right for finding a way to serve victims of violence in an improved manner. I knew this

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was a way I could work as a nurse and be very involved in the field of rape and child abuse, which was both meaningful, exciting, and rewarding.

Crowley says that at the time, sexual assault was somewhat unchartered waters, even as child abuse was well understood and studied. However, certain medico-legal processes were still lacking: In 1986, it was very unusual for a young child to go to court and testify; there had to be a lot more evidence, and so much of the work forensic nurses do now in the area of child abuse—other than rote evidence collection—working with victims and doing a history—has helped a lot more of those cases get to trial. The field of child abuse has always had more of a body of literature and research than adult sexual assault. At the time, the battles we fought were, can nurses do this exam? Are we going to be adequate to testify in court? Do we have the support of the local prosecutors? Do the police want us to do their cases? Will the crime lab think we can do the rape kit correctly? Can we learn all this? And then, will the medical field accept us as colleagues?

The answer, of course, is yes, but Crowley says that at the time, nurses had to prove themselves: The 1980s were very much a proving ground for nurses and what they could do. The timing was right, however, so I think that had a lot to do with nurses’ eventual success. Physicians didn’t like the hassle of going to court on sexual assault cases, and they were overloaded in the ER, so there was a void, work that needed to be done. And the nurses filled that role beautifully. There was a definite medico-legal need because the existing system really wasn’t able or willing—not unwilling, just that they were overextended. Many medical personnel didn’t have the forensic training necessary. I used to affectionately be told by ER staff, “We love you and we’re so glad of the work you do, but we hate to see you coming, because we know what that means.” Trauma, like a motor vehicle accident, was one thing, but when a sexual assault victim came in, it was much more difficult for the staff without forensic nurses.

Whether it is sexual assault or medico-legal death investigation, Crowley says forensics is a natural fit for nurses. “The stage was already set,” she says: Even a lay observer could tell tht forensic nursing was well within the scope of practice for a nurse. It was really no different, I don’t think, than being in the ER or the ICU, when you look at the kinds of care provided and the medico-legal approach. The only thing different was, could nurses develop the technical forensic skills that typically belonged to the realm of the physician or the law enforcement officer, or even the nurse practitioner. Those were bigger issues than forensic concepts; some

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Forensic Nursing

people really focused on the nursing process and how forensics fit into it. For a lot of us, it was really more about learning the specific medico-legal skills because we knew we already had the expertise of documentation and working with patients down cold. It was natural to extend forensic work to the care of patients; it really became more a matter of plugging in the forensic pieces in other clinical responsibilities. I have always seen all of us—doctors, nurses, law enforcement, prosecutors—as a team. I’ve always been able to work well with physicians and all other allied health professionals, and now in the forensic community, collegiality extends to the criminalists and to the police. It may be different players, but it’s no different in terms of the team concept. Different people bring different talents to the forensic arena. The forensic nurse is a vital member of that team.

6.10.5 GENITAL INJURY: AN ISSUE COURTROOM

IN THE

In the more than two decades since formal SANE/SART programs were developed, experts are still pondering the likelihood of genital injury following sexual assault. This type of injury is frequently an issue in the courts, with the expectation that injuries will be discovered and documented in “genuine” cases. In some jurisdictions, rates of conviction are higher when the complainant has genital injuries. Palmer, McNulty, D’Este, and Donovan (2004) consulted assault records and forensic examination findings of 153 women who attended a sexual assault service in Newcastle, Australia between 1997 and 1999. All of the women were examined within 72 hours of their assault. One hundred eleven (73 percent) of the women were under the age of 30, and 4 percent were over the age of 50. Eighty-six percent of the cases were penile–vaginal penetration. Nongenital injuries were found in 46 percent of the women examined, and genital injury was found in 22 percent. Palmer et al. (2004) write, “Genital injury following sexual assault carries undue influence in obtaining convictions.” Bowyer and Dalton (1997) concluded that the courts in the United Kingdom rely on medical evidence, especially genital injury, to prove sexual assault even though many studies report that a minority of women suffer such injury. Estimates of genital injury following sexual assault have ranged from 7 percent to 87 percent of women, depending on the method of detection used (Girardin, Faugno, Seneski, & Slaughter, 1997; Slaughter & Brown, 1992). Examinations using tissue staining and colposcopy have higher rates of genital injury noted than unaided examination. Some findings such as redness and swelling could have been physiological responses or due to unrelated conditions. Nevertheless, most injuries related to sexual assault are minor. Severe genital trauma was reported in less than 5 percent of women and fewer than 2 percent of genital injuries required hospital admission and medical treatment.

Palmer and colleagues reported in their study that 61 percent of the women interviewed knew their assailant, and 51 percent of the women were assaulted in either their own home or the home of the assailant. Two hundred fiftythree separate sexual acts allegedly were perpetrated on the victims, most commonly penile–vaginal penetration, either attempted or completed. A weapon was present in 11 percent of the assaults, and threats of violence were reported by 18 percent of the women. Nongenital injuries were detected in 70 women; 66 percent of injuries were deemed minor, 24 percent moderate, and 10 percent severe. Injuries consisted of bruises (54 percent), abrasions (40 percent), and lacerations (4 percent). Three women were hospitalized due to the extent of their injuries. The physical sites of the injuries were the limbs (50 percent); back and buttocks (25 percent); head, face, and neck (15 percent); and abdomen and chest (10 percent). Genital injuries were detected in 33 women; 61 percent of injuries were deemed minor, 33 percent moderate, and 9 percent severe. Injuries were chiefly abrasions (59 percent), bruises (22 percent), and lacerations (16 percent). One woman was hospitalized due to the severity of her injuries. The most common site of injury was the vulva (49 percent), upper inner thighs (22 percent), and the perianal area (20 percent); vaginal injuries represented 8 percent of cases. Half of the women had neither nongenital nor genital injuries. The researchers discovered that less than one third of the women studied had genital injuries documented, and most were minor. Their research confirms many U.S. and British studies that found a majority of women who reported sexual assault had clinical evidence of genital injuries. The researchers drew several conclusions: •

•

•

•

•

There are limitations to the measurement of injury after alleged sexual assault, as bruising can take days to appear, and some injuries might not have been present at the time of the examination. Conversely, preexisting lesions could have been assessed as being caused by the assault. Interobserver error could be introduced into a case, as different physicians were involved in the medical examinations of the women. As many sexual assaults go unreported, women with injuries might not seek care, and so it might not be appropriate to generalize findings of the study to a larger group of women who do not seek medical treatment. Reporting bias could be present, as the majority of the women were assaulted by known assailants. The likelihood and extent of genital injury following penetration is dependent on the following factors: the state of the genital tissues; their

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•

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lubrication, durability, and integrity; the dimensions of the penetrating object; and the degree of force involved. It is usually impossible to differentiate the effects of digital from penile penetration, regardless of the victim’s age and hormonal status. Therefore, genital injuries can be due to individual factors or the combined result of penile, digital, or foreign-body penetration of the anus and the vagina.

The researchers discovered several significant factors associated with injury following sexual assault: •

• •

The presence of nongenital injury had an odds ratio of 19 for the presence of genital injury, which reflects the findings of other studies. Threats of violence were independently associated with genital and nongenital injuries. Assault by a known assailant had lower odds of nongenital and genital injuries than assault by a stranger. The researchers conclude, “Debate persists as to the likelihood and frequency of genital injury following consensual intercourse as opposed to sexual assault. Studies comparing genital findings on unaided examination of women following consensual intercourse and of women who have been sexually assaulted are needed. Nevertheless, this study should redress the misperception that genital injury is a necessary finding following sexual assault.”

6.10.6 USE OF COLPOSCOPY EXAMINATIONS

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SEXUAL ASSAULT

In the past 15 years, a standard in the use of the colposcope for photo documentation of child and adult sexual assault cases has been established, with an increasing appreciation for the use of video colposcopy in this patient population. Although a comprehensive history and interview are crucial components of the examination process, forensic nurses must have a thorough understanding of the significant medical-clinical evidence involved in sexual assault cases. Two types of medical evidence exist: laboratory (forensic evidence and STDs) and clinical, or the documentation of traumatic and psychological injuries. It is obvious to health care providers that laboratory evidence can be definitive when there is evidence of ejaculation; however, it has become increasingly important to provide clinical documentation of trauma associated with assault, as many cases are presented without forensic evidence or with legal strategies claiming that the sexual act was consensual. In recent years there has been an increased understanding of the significance of medical (clinical) findings in sexual assault. Researchers have reached a consensus

on those clinical findings of trauma and variants of normal and nonspecific changes. Colposcopy, with the addition of video and computer technology, has changed with the times and has become more sophisticated, directly addressing the medical community’s increasing dependence on photo documentation in assault cases. The primary benefit of colposcopy is the single examination, which can be reviewed with experts and provided to the legal system, avoiding the need for numerous examinations and examiners. Astrid H. Heger, MD, executive director of the Violence Intervention Program at the Los Angeles County and University of Southern California Medical Center, where she is also an associate professor of clinical pediatrics, reports that video colposcopy adds an additional dimension, as the examination can be virtually re-created via videotape—an important factor when evaluating the adolescent or adult patient. In these patients, the estrogenized hymen tends to be more dynamic and moves during the examination, so video documentation allows the examiner to evaluate all of the folds and clefts that might be missed during still photography. Additionally, video colposcopy gives teaching programs the ability to instruct through closed-circuit video, rather than having numerous evaluators in the room during the examination. Heger states: With the increased reliance on nurse specialists or forensic nurses, the video documentation allows for the physician back-up to review and participate in both diagnosis and treatment, and the legal processes. This collaboration improves the quality of the evaluation for the patient and the system, while giving the patient access to a medical setting staffed by caring professionals. The primary use of photographic documentation by the legal system has been in the substitution of photographs for re-examination. Defense and court-appointed experts can review prior evaluations easily without additional trauma to the patient. This use of colposcopy in the diagnosis of sexual abuse of children and adult victims of sexual assault has been upheld by the appellate court of California and its use is described as being nonexperimental . . . Video colposcopy will not replace the meticulous, sensitive, welltrained professional, but it can bring the best of documentation and accountability to a diagnosis which must be made accurately and scientifically for the protection of both the victim and the system. This is truly a case where a picture is worth a thousand words.

6.10.7 SEXUAL ASSAULT EXAMINATION, REPORTING, AND THE LEGAL OUTCOME OF CASES Although not completely nonexistent, there is a paucity of information on the relationship between medico-legal evidence and the laying of charges in sexual assault cases. Here is a look at several recent studies. One Canadian study outright questions the “uncritical” collection of medical forensic evidence as it relates to the laying of

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charges. Du Mont and Parnis (2000) say that because very little is known about the role of medical evidence in the legal resolution of sexual assault cases, they conducted a retrospective review of hospital and police records to determine whether medico-legal evidence was related to the police laying of charges. Data were obtained from 187 female sexual assault victims who presented to a large urban hospital-based sexual assault treatment center and the police in Ontario, Canada between January 1 and December 31, 1994. Using stepwise logistic regression, medico-legal variables were tested while controlling for nonmedical factors. Neither the collection of sperm, semen, and saliva, nor the documentation of clinically observed injuries, was significant in predicting an arrest and charge. In contrast, nonmedical variables such as the victim’s age, use of alcohol, resistance and relationship to the assailant, and the corroborating evidence of a witness were related to charge-laying. Wiley, Sugar, Fine, and Eckert (2003) wanted to better describe the assault characteristics and examination findings in sexual assault victims who pursue legal action. They performed a case-control study of consecutive women older than 15 years who came to an urban hospital after sexual assault over a 32-month period. All of the women underwent a standardized history and physical examination by a resident in obstetrics and gynecology. Of the 888 women undergoing evaluation in the ED, 132 (15 percent) had charges filed by the prosecutor. Characteristics positively associated with a legal outcome included being examined within 24 hours after assault, partner or spouse as an assailant, oral assault, and anogenital trauma. Amnesia at the time of assault and friend or acquaintance as assailant were negatively associated with a legal outcome. Sexual assault and abuse crimes often go unpunished because many cases go unreported; however, even when victims do come forward, it can be a difficult crime to prosecute. A recent study by Rennison (2002) that looked at survey figures for the years 1992 to 2000 found that only about 36 percent of forcible rapes experienced by females age 12 and older were reported to law enforcement officials. Langan and Farrington (1998) say that of reported assaults, only about one fifth actually result in arrest, prosecution, and successful conviction. A sexual assault is a personal crime that can be emotionally and physically traumatizing, and reporting it might be daunting when the assailant is someone the victim knows. Greenfeld (1997) found that in about three out of four assaults, the victim and offender are acquainted, intimate partners, or from the same family. In another study of police-recorded data on children under age 12, some 90 percent of the children raped knew the offender (DOJ, Bureau of Justice Statistics, 1993). The medical evidentiary examination then becomes an even more important component in the medico-legal process. The

Forensic Nursing

examination must be performed competently and comprehensively if the evidence gathered is to stand up in a court proceeding that might occur weeks, months, and sometimes years after an assault. McGregor, Le, Marion, and Wiebe (1999) state that few studies have examined if there is a correlation between medical findings and legal outcomes in sexual assault cases. Rambow et al. (1992) found that evidence of genital or nongenital trauma was significantly associated with conviction in cases in which there was an identified suspect and the victim was willing to testify. Penttilla and Karhumen (1990) determined that little correlation existed between the severity of a victim’s injuries and the outcome of the case. Schei (1995) discovered that conviction was related to the occurrence of severe violence, documentation of genital injuries, and presence of sperm at the time of the evidentiary examination. In their retrospective cohort study, McGregor et al. (1999) reviewed the charts and medico-legal reports for all cases of sexual assault handled by the BC Women’s Sexual Assault Service in 1992 for which a police report had been filed. Ninety-five cases were identified; in 10 cases, no injuries were documented at the time of the examination. The degree of injury was rated as mild in 26 cases (27 percent), moderate in 56 cases (59 percent), and severe in 3 cases (3 percent). In 31 cases, there was documented genital injury. After adjustment for income level and the patient’s knowledge of the assailant, the odds ratio for charge-laying in a sexual assault case with documented moderate to severe injury was 33.3. Socioeconomic status above the group median and knowledge of the assailant were also associated with charge-laying. Presence of genital injury per se, age of the patient, and the detection of sperm by microscopy at the time of the examination were not associated with the laying of charges. The researchers concluded that the extent of documented injury is associated with the laying of charges in cases of sexual assault; however, questions remain as to the effectiveness of the medical component of evidence collection. The researchers approached the study with the questions of, “Is there an association between the extent of documented physical injury and legal outcome in cases of sexual assault?” and “What other factors are associated with legal outcome in these cases?” McGregor et al. write: Answers to these questions should provide insight into how a health care provider should apportion his or her time between the forensic component of the exam, educating the patient about treatment after the assault, and assisting the patient to debrief after the experience. If particular aspects of the physical exam, such as detection of sperm or documentation of genital injury, are strongly associated with a positive legal outcome, sexual assault services could direct greater resources to training in the collection of forensic evidence in these areas.

Sexual Assault

In 31 cases (33 percent), charges were laid, and in 11 of these cases there was a conviction. Of the 11 convictions, 10 were for sexual assault and one was for common assault, or an assault that does not involve a weapon and does not result in serious bodily harm. For the perpetrators who were charged, there was a stay of proceedings in another 11 cases. Under Canadian law, a stay of proceedings is often entered if a victim or witness is unable or unwilling to testify, and there is insufficient evidence to proceed. McGregor et al. report that the most common outcome for the cases in which charges were not made was that the case became inactive due to lack of information (28 cases); the second most common outcome (13 cases) was a designation that the victim did not want to proceed. Among the perpetrators who were convicted, sentences ranged from 21 days to five years, and in once case of a multiple offender, a life sentence was handed down. Charges were laid in 1 of the 10 cases with no injury, 6 of the 26 cases with mild injury, 22 of the 56 cases with moderate injury, and 2 of the 3 cases with severe injury. McGregor and colleagues report that during the year of the study, too few convictions provided sufficient means for analysis; however, they say: The laying of charges was a reasonable positive legal outcome for the analysis, for without a charge, there can be no conviction. The proportion of cases in which there was evidence of genital injury, excluding tenderness, was similar to that reported in previous studies, which have found that visible genital trauma is relatively uncommon in sexual assault. The lack of an association between chargelaying and genital findings suggests that increasing the time devoted to documenting microtrauma of the genital region by means of colposcopy may not be appropriate.

McGregor and colleagues sum up their study by reiterating that their study results support the theory that there is an association between the laying of charges and the presence of documented moderate or severe injury. “It is important to have good evidence that the time spent on the forensic part of the examination does indeed influence the legal outcome of the case.” McGregor and colleagues readdressed the issue of evidence related to successful prosecution. This time they conducted a retrospective chart review of all policereported cases seen from January 1993 to December 1997 at a sexual assault center. They reported that charges were filed in 151 (32.7 percent) and a conviction secured in 51 (11 percent) of 462 cases examined. Genital injury was observed in 193 cases (41.8 percent) and semen-positive forensic results were obtained in 100 cases (38.2 percent). In 197 cases (42.6 percent) the assailant was known to the victim before the attack, and 21 cases (4.5 percent) involved multiple assailants. Slightly more than three fourths of victims reported vaginal, anal, or foreign-object penetration. Genital injury was noted in 193 cases (41.8

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percent), and police files documented receipt of forensic samples from the forensic examiner in 327 cases (70.8 percent). Of the 262 cases in which forensic samples were analyzed, 100 samples (38.2 percent) tested positive for the presence of sperm. DNA testing was performed in eight cases (1.7 percent). The most common documented extragenital injury was bruising, seen in 301 cases (65.2 percent), with lacerations being relatively uncommon (18.6 percent). In the McGregor (1999) study, a suspect was identified in 280 cases (60.6 percent), and a conviction was secured in 51 cases (11 percent). At the time the study was conducted, one case remained before the courts. The researchers discovered that perpetrators were found guilty as charged in 33 cases (7.1 percent) and guilty of a lesser charge in 18 cases (3.9 percent). In 40 cases (8.7 percent), a custodial sentence was rendered. The period of incarceration varied from seven days to more than 14 years. McGregor et al. write, “Previous authors have cited provision costs and time, victims’ experience of the evidence collection process as invasive and traumatic, and victims’ expectation that the examination would prove an assault took place as reasons for evaluating medical-legal findings in sexual assault.” The researchers added that the proportion of cases with observed genital injury was somewhat higher in their study than in previous studies, which might be explained by the use of colposcopic examination. The researchers say the low rate of findings of sperm can be explained by time delays in presenting for examination, douching after an assault, variations in the vaginal environment, sexual dysfunction of the assailant, and the use of condoms. The researchers caution, “When testifying in court, examiners need to educate the judge and jury regarding how these tests should be interpreted. Failure to do so might leave the court with the false impression that negative results negate the possibility that a sexual assault has occurred.” The researchers add that positive associations of documented injury with charge filing and conviction is “an important step in confirming the value of injury documentation in the forensic examination of sexual assault victims.” They add that positively associating injury with conviction is consistent with other studies and that it is not surprising, “given that more than half of cases proceeding through the criminal justice system involve an assailant known previously to the victim, which is likely to make corroboration of consent through injury documentation a common issue at trial.” One of the most important points the researchers tried to make was the causation between the presence of forensic evidence collected by an examiner and the increased incident of charges being filed. They write, “The greater than threefold increased likelihood of charges being filed in the presence of forensic samples collected by the examiner, irrespective of the test results, suggests that a victim’s willingness to submit to a forensic examination might play a role in assessing the strength of a case.” They add, “The examiner’s collection

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of biologic samples for submission to police appears to provide some perceived scientific validation of a victim’s allegations.” What this study might do for the encouragement of reporting and laying of charges is contrasted with the damage it might do to the use of colposcopic examination. McGregor and colleagues report that the lack of genital injury alone with either charge filing or convictions suggests that efforts to focus on visualizing microtrauma of the genital region in sexual assault forensic examinations “might be misguided.” They say further, “This is particularly relevant considering the costs of colposcopy, the need for technical expertise and familiarity with colposcopic examination of normal patients, and care providers’ need to apportion time between evidence collection, medical care, and counseling.” They also add, “As described by Patel (1993), the procedure is a potentially ‘stressful invasion of a woman who is already vulnerable and at risk of the rape trauma syndrome.’ Future evaluation of colposcopic technology with respect to its effect on victim–provider interactions, the victim’s experience of care provision, and its relationship to securing greater numbers of convictions is important.” Gray-Eurom, Seaburg, and Wears (2002) at the University of Florida Health Science Center also set out to determine the association between historical and physical evidence with the judicial outcome of sexual assault cases. They conducted a population-based, retrospective review of forensic evidence for all sexual assault cases reported in Duval County in Florida during a two-year period. The variables examined included age, race of victim, evidence of trauma—whether body, genital, or both—presence of spermatozoa at the time of the forensic examination, weapon use, and whether the victim knew the assailant. In cases in which an arrest was made, logistic regression was used to estimate the strength of association with the outcome of conviction in sexual assault cases. During the study period, 821 sexual assaults were reported, and 801 forensic examinations were performed. Seven hundred seventy-six (97 percent) of the victims were female. A suspect was identified in 355 (44 percent) of the 801 cases for which a sexual assault forensic examination was conducted. No suspect was identified in 446 (56 percent) of these cases. Two hundred seventy-one arrests were made, and police did not have enough evidence to arrest a suspect after detention in 84 cases. For those cases in which a suspect was arrested, 153 had charges dropped, 89 were found guilty, 2 were found not guilty, and 27 cases were still pending or the files were sealed and unavailable for review. There was evidence of trauma in 202 (57 percent) of the examinations, and sperm were found at the time of the forensic examination in 110 (31 percent) of the cases in which a suspect was identified. By using logistic regression, the researchers found that victims aged younger than 18 years, the presence of trauma, and the

Forensic Nursing

use of a weapon by the assailant were significantly associated with successful prosecution. There also was a trend toward conviction if the victim was White. The researchers concluded, “Emergency physicians have an obligation to provide care for victims of sexual assault cases. This care includes a possible legal defense. To that end, emergency physicians should be vigilant in the documentation of the history of the event and in the documentation of traumatic injuries because these factors can assist in a successful prosecution.” One of the more definitive cases involving pattern injury and court testimony in a sexual assault is a 1997 case that represented the first successful prosecution of an acquaintance rape case in a county. Hohenhaus (1998) described the case of a 40-year-old woman who presented to the ED of a tertiary-care teaching hospital in September 1997. She reported being sexually assaulted by an acquaintance earlier in the evening. When the SANE performed routine evidence collection, the nurse examined the patient’s genital area with a colposcope before and after application of toluidine blue dye. On first examination, the patient had a 2-cm tear at the 6 o’clock area of the posterior fourchette, as well as redness extending from the 6 o’clock to the 7 o’clock position. The visible tear had a positive uptake of toluidine blue dye, and the speculum examination revealed petechias of the cervix, with some minimal bleeding noted from the cervical os. The SANE photographed the injuries per standard protocol, and recorded the opinion that the injuries were consistent with nonconsensual intercourse. The defendant was charged with second-degree rape, and the case went to trial on May 13, 1998. Hohenhaus reported that at the pretrial conference, the defense attorney provided the assistant district attorney and the SANE with several photographs of the defendant’s penis with a metal ring through the base of the glans. The defense stated that the injuries found in the patient’s genital area were the result of the defendant wearing this ring during consensual intercourse, although the patient denied during testimony that she had observed this ring. During the SANE’s testimony, the defense inquired as to whether the injuries observed during the patient’s examination could have been caused by the ring. Although this was possible, Hohenhaus writes, “further study of the photographs of both the patient and the defendant revealed an interesting note, based on the defense’s opinion of how the injuries occurred.” The defense claimed that the clasp on the ring caused the victim’s genital tear, rather than injuries sustained during nonconsensual intercourse. The SANE acknowledged that this was possible, but that the tear was more consistent with blunt-force trauma as opposed to sharp-force trauma. The SANE asked the defense if the ring was inserted from the same direction each time it was used; when the defense replied that it was always placed from his right to his left, the SANE explained that it was highly unlikely that the

Sexual Assault

injury noted would have been caused by the clasp on the ring because the injury then more likely would have been noted at the 7 o’clock position of the posterior fourchette. Hohenhaus reported that during the three-day trial, the SANE testified for four hours and was called back by the jury for clarification of some of the issues regarding “left and right” as presented in the medical evidence. After deliberating for two hours, and after requesting only the photographs and the medical record, the jury returned with a verdict of guilty. Hohenhaus writes, “Understanding mechanism of injury plays an important role in the examination of victims of sexual assault. In this case, the SANE’s expertise in patterned injury interpretation was a major factor in the conviction of a rapist.”

6.11 DRUG-FACILITATED SEXUAL ASSAULT Although alcohol has long been used to facilitate sexual assaults, today newer, memory-erasing drugs such as rohypnol, ketamine, gamma hydroxybutyrate (GHB), gamma butyrolactone (GBL) and many others are being used in drug-facilitated sexual assault. Symptoms include a history of having only a couple of alcoholic beverages but quickly becoming extremely intoxicated. The victim can often remember very little of the incident other than flashes, sometimes referred to as cameo appearances, until she awakens. She might then find herself undressed, or partially dressed, with vaginal or rectal soreness making her believe she has been raped (Ledray, 1999). Whenever a victim of a potential drug-facilitated sexual assault (DFSA) is seen within 72 hours of the likely assault, a urine specimen should be collected for a drug screen analysis, according to the ACEP (1999). Although 72 hours is the recommended time limit because most substances cannot be detected beyond that time, newer techniques of drug analysis are being developed and the time frames might change. Although the technique is still under study, a new process of analysis can now detect a 2-mg dose of flunitrazepam for up to 28 days after ingestion. Once developed, these processes will allow for the identification of substances as long as 28 days postingestion of a single 2mg dose of flunitrazepam (Negrusz et al., 2000). Even though there is little memory and perhaps no certainty of a sexual assault, whenever the victim’s story is consistent with a DFSA, or suspicious, the forensic examiner should collect a urine specimen for DFSA analysis as a part of the sexual assault evidentiary examination. If the victim calls prior to coming to the hospital or clinic, she should be told to not void unless necessary, and if she must void to collect her first voided urine in a clean container and bring it with her (Anglin, Spears, & Hutson, 1997).

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Some assailants use drugs to facilitate sexual assault. A woman who has been plied with drugs is easier to control, to the extent that physical force is not necessary, as the drugs will render her submissive and incapacitated and, in some cases, unconscious. In this respect, the increased use of so-called “date rape” drugs in recent years has received much attention (WHO, 2003). In some cases of sexual assault, defense attorneys might tap into societal prejudices against the use of alcohol or drugs by women to cast further doubt and disdain on the victim. Forensic nurses should be aware of the facts and issues associated with DFSA. Kintz, Villain, and Ludes (2004) explain that the use of a drug to modify a person’s behavior for criminal gain is not a recent phenomenon; however, the recent increase in reports of drug-facilitated crimes such as sexual assault has caused alarm in the general public. Drugs involved in DFSA can include pharmaceuticals such as benzodiazepines (flunitrazepam or lorazepam), hypnotics (zopiclone or zolpidem), sedatives (neuroleptics, some histamine H, antagonists), or anesthetics (GHB or ketamine); drugs of abuse such as cannabis, ecstasy, or lysergide; or more often ethanol. Drugs used to facilitate sexual assaults can be difficult to detect (active products at low dosages, chemical instability), possess amnesic properties, and can be rapidly cleared from the body (short half-life). The researchers say that in these situations, blood or even urine can be of little help, and this is the reason why this laboratory developed an original approach based on hair testing. Hair was suggested as a valuable specimen in situations where, as a result of a delay in reporting the crime, natural processes have eliminated the drug from typical biologic specimens. Although there are many papers focused on the identification of drugs in hair following chronic drug use, those dealing with a single dose are very scarce, Kintz et al. state. They add that hair analysis might be a useful adjunct to conventional drug testing in sexual assault; it should not be considered an alternative to blood and urine analyses but as a complement. Testa, Vanzile-Tamsen, and Livingston (2004) examined the impact of perpetrator and victim substance use on the sexual assault outcomes of penetration and victim injury. More than 1,000 women ages 18 to 30 were recruited from households using random digit dialing. Women who reported sexual assault since age 14 (359) were interviewed face-to-face regarding their most recent sexual assault incident. As hypothesized, the researchers report that high levels of perpetrator intoxication decreased the likelihood of penetration occurring. When the victim was highly intoxicated however, penetration was more likely. Victim injury was more likely in assaults involving penetration. Higher levels of perpetrator intoxication in assaults involving a sober victim were also associated with greater odds of victim injury.

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Forensic Nursing

In another study, Testa, Livingston, and Collins (2000) examined the impact of alcohol consumption on women’s risk perceptions and intended behaviors in a hypothetical situation in which the potential for establishing a relationship with an attractive man was coupled with the potential for sexual aggression. Fifty-nine single women, ages 21 to 29, were randomly assigned to one of three beverage conditions: (a) alcohol (dose sufficient to raise blood alcohol level to .08); (b) placebo, in which they were led to believe that they had consumed alcohol but had not; or (c) no alcohol, in which they neither expected nor received alcohol. Compared with women in the no-alcohol condition, women in the alcohol condition rated the male character in the vignette more positively, anticipated less risk and more benefit resulting from a series of behaviors likely to facilitate the relationship while increasing sexual vulnerability (e.g., engaging in consensual sexual activities), and anticipated greater involvement in those behaviors. The placebo appeared to exert similar but weaker effects. McGregor et al. (2003) conducted a retrospective review of sexual assault cases seen in an ED from 1993 to 1999, as well as examined rates and characteristics of suspected DFSA. Overall, 12 percent of cases were identified as suspected DFSAs. The researchers reported that the rate of suspected DFSA in 1999 was more than double that in the preceding six years, and as compared to other sexual assaults, suspected DFSA cases had a longer time delay in presenting to the hospital, were less likely to involve the police, and had a lower occurrence of both genital and extragenital injury. Ledray (2001) explains that at her facility’s Sexual Assault Resource Service in Minneapolis, not every individual who might have been drugged and sexually assaulted is administered a drug screen; rather, examiners look for a presenting clinical symptom pattern consistent with DFSA and a history of drug ingestion within 72 hours. Ledray writes, “It has been our experience that what many of these men and women really want is a clear assessment of the likelihood of their having been drugged and raped. A detailed interview and examination for injuries or trauma can often be less costly and more helpful than a drug screen.” Ledray adds that examiners look for the following: •

•

A history of being out drinking, having just one or two drinks that would not account for the extreme level of intoxication, suddenly feeling disoriented, or suddenly appearing drunk or drowsy with impaired motor skills, judgment, or amnesia. Reports that the victim looked or acted intoxicated within about 15 minutes after drinking a beverage that he or she accepted from someone, or drinking a beverage that was left unattended.

• •

• •

The victim remembers very little of the incident after accepting the beverage until awakening. The victim awakens hours later and finds himself or herself undressed or partially dressed, possibly in bed with a person he or she might or might not know, or the victim awakes with vaginal or rectal soreness, indicating sexual contact might have occurred without consent. Possible nausea and vomiting on awakening. History of being at a party or a rave where drugs such as Ecstasy or “Special K” might have been available.

Ledray reports that the recommendation of the June 2000 national forum is that when the forensic examiner determines that an assault history is suspicious of DFSA, a blood and urine specimen should be collected as soon as possible, and that a chain of custody is maintained. It has been recommended that blood and urine specimens be collected for up to 72 hours after ingestion; Ledray writes: It is unlikely that positive results of a blood test will be obtained beyond 24 hours and that test results will be positive beyond four to six hours with substances such as GHB . . . urine is a better specimen than blood for detection of metabolites of most of the many drugs used to facilitate a sexual assault. With use of current technology, substances such as flunitrazepam (Rohypnol) are rarely detected beyond 24 hours after ingestion, and GHB is only detectable in the urine for six to 12 hours after ingestion, resulting in many false-negative results.

Ledray recommends to examiners that when dealing with victims who suspect that they have been drugged and raped, these victims should be instructed that if they must urinate before coming in for a forensic examination, they should save their first voided urine and bring it with them. Ledray says the examiner should take possession of the urine and begin the chain of custody from that point. “In an attempt to strengthen the chain of custody, the SANE should also document when the urine was collected by the victim, where it was kept between the time it was collected and when the SANE took possession of it, and who else had access to the urine,” she writes: Both this urine and the first urine voided in the emergency department should be sent for toxicologic analysis. Although it is uncertain whether the results of this urine test will be admissible in the courtroom as evidence because of chain-of-custody issues that will likely be challenged, it should still be collected. It will be the most accurate specimen, and even if it has no forensic value, the information may be helpful to the survivor in putting the pieces together for recovery.

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Forensic scientists say that head hair is also a source for identification of some drugs, however, false-negative results often are found, Ledray asserts. She adds: When hair is to be used for drug screening, it should not be collected as a part of the initial SANE evidentiary examination. The hairs do not need to be pulled, but they should be cut close to the skin. With special equipment and procedures . . . drugs may be detected in hair samples as early as 24 hours after ingestion; however, toxicologists prefer hair specimens collected 14 days later to allow for absorption of the drug into the hair with growth of the hair.

Ledray states that SANEs should identify those laboratories that can conduct a sensitive drug toxicology screen when a blood, urine, or hair specimen is obtained for DFSA testing, because numerous crime laboratories can identify benzodiazepines but not flunitrazepam, for example. “State crime laboratories will only do the specific test when it is requested by law enforcement agencies. It is not routine for them to do a broad drug screen, and they may have a limited capacity to do so,” Ledray writes. In the same vein, SANEs should work closely with their local law enforcement agencies to ensure that all substances in question are accounted for during testing. Ledray explains: Current standards suggest that if a complete drug screen is going to be conducted, it is essential that the SANE inform the victim what drugs will be included in the screen. It is also important that the SANE explain that if the victim has recently used drugs recreationally or by prescription, they may be detected in the screen. If the victim has recently used drugs, it is important that the SANE know this ahead of time in order for it to have the least negative impact on the victim’s credibility. In most communities, if voluntary use of illegal drugs is not disclosed until after positive results of a drug screen have been obtained, it can do irreparable damage to the victim’s credibility. An otherwise good case may not go forward as a result. However, if the drug use is disclosed, it is more likely that the prosecutor will decide he or she can either exclude the information from court or deal with it in court.

Ledray adds that victims should be informed as to whether or not they might be charged criminally if they admit to illegal drug use, as well as how police and prosecutors might view a positive screen for an illegal substance and the potential impact on the investigation and charging of their case. Drug testing is not an inexpensive proposition, and Ledray states that a comprehensive drug-toxicity screen could cost more than the total amount available to most SANE programs as reimbursement for the complete sexual assault evidentiary examination. She states:

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It is unreasonable to expect the SANE program or the medical facility to assume this cost without adequate reimbursement. The solution of many other SANE programs across the United States has been to turn over the biological specimens collected to the appropriate law enforcement department with the rape kit. The law enforcement department will then be responsible to pay for a drug screen if one is requested by their department. If a report is not made but the victim or his or her family wants a drug screen, the victim should be informed that he or she or his or her insurer will be responsible for paying for a drug screen if one is sent to a private laboratory. The victim should also be informed what the cost will be. When a drug screen is completed for other than medical purposes, many insurers will not assume the cost.

Suzanne R. White, MD, FACEP, FACMT, medical director of the Children’s Hospital of Michigan Regional Poison Control Center, writes, “While it is estimated that 1 in 4 women in the United States will be raped in their lifetimes (with 75 percent of those rapes acquaintance or date rapes), this form of assault is likely underreported secondary to complex feelings of guilt or the common belief that the woman was responsible for the assault. While increasingly reported, the true incidence of chemically-mediated date rape is therefore unknown.” Alcohol has long been used to facilitate nonconsensual sex and remains the most popular “drug” of choice. In recent years, however, the use of “date rape” drugs has been implicated in an increasing number of cases of sexual violence. The most commonly used drugs are flunitrazepam (Rohypnol) and other benzodiazepines, GHB, ketamine, cocaine, methamphetamine, and marijuana. Victims might be unaware that they have been drugged and that they have been sexually violated. A double standard often exists between men and women in terms of drinking alcohol or using drugs. If a woman has been drinking or using drugs she is often blamed for her victimization. Conversely, the perpetrator’s behavior is excused or justified because he was “under the influence” and thus not expected to control his behavior. Health care providers must be aware of the signs that are suggestive of drug-facilitated sexual violence. If patients present with any of the following symptoms, the use of drugs or alcohol should be suspected: • • • • • •

Impaired conscious state, memory loss, disorientation, or confusion Impairment of speech or coordination Unexplained signs of trauma, particularly genital trauma Apparent intoxication not corresponding to stated alcohol consumption Unexplained loss or rearrangement of clothing Talking about having an “out-of-body experience”

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•

If drugs or alcohol are suspected, it is important to be aware of the following: • Any alteration in conscious state requires immediate access to full resuscitation facilities, such as those available in EDs. • The sooner specimens are taken (e.g., blood, urine) the greater the likelihood of successfully detecting any substances not knowingly taken.

Forty-six percent of women report that they have experienced attempted or completed forced sex by an intimate partner or ex-partner at some time in their lives. Rape and domestic violence account for an estimated 5 percent to more than 15 percent of healthy years of life lost to women of reproductive age (WHO, 2003). The following is a closer look at common date rape drugs. Flunitrazepam (Rohypnol) is a benzodiazepine developed by Hoffmann-La Roche in 1960 to be used for the short-term treatment of insomnia. It is 10 times more potent than diazepam, possessing both hypnotic and amnestic properties that predominate over its other sedative, anxiolytic, muscle-relaxing, and anticonvulsant effects. Sexual activities involving the use of Rohypnol have been reported by both male and females to be consensual in most instances. Authorities in numerous states and on college campuses report that the drug is increasingly being given to females without their consent. Flunitrazepam is typically combined with alcohol or other drugs as an “extender” while the user gets a high. It is odorless, colorless, and tasteless. Recent changes by the manufacturer include a reformulation of the tablet to include a dye pellet that both renders a blue discoloration to and leaves a particulate residue in dissolved liquids. Abrupt onset of action is noted within 15 to 30 minutes of ingestion. Peak levels occur within one to two hours. Active metabolites are present and the total duration of action is about eight hours. Most commonly, early effects include drowsiness, dizziness, incoordination, and impaired judgment and reaction time. Disinhibition or aggression have been associated with behavioral toxicity leading to dangerous behavior on the part of the user. Memory loss is characteristic, with blackouts lasting for eight to 24 hours. Other less common effects include gastrointestinal upset, hiccoughs, blurred vision, dry mouth, and a “hangover” sensation. Life-threatening symptoms such as coma, respiratory depression, or apnea are most commonly seen following combination with other sedatives, but death from flunitrazepam alone is also described. Early specimens are most useful as peak blood levels occur within one to two hours of ingestion. Detection of a 1-mg dose in the blood for up to 12 hours and urine for 60 to 72 hours (as the metabolite 7-aminoflunitrazepam) is possible.

Ketamine is an anesthetic agent that is diverted from legitimate human or veterinary use. It is commonly abused in the rave party setting and has been implicated in cases of date rape. It is available as a clear liquid that is usually dried and then sold in small bags, paper folds, foils, vials, or capsules. The powder is then snorted, put into drinks, injected, or smoked. The liquid form has also been abused as a nasal spray. Ketamine is a short-acting dissociative anesthetic that is structurally similar to phencyclidine (PCP). Its sites of action within the central nervous system include the N-methyl-D-asparate (NMDA) receptor complex and muscarinic receptors. With subanesthetic doses of either parenteral or oral ketamine (70 mg on average), the onset of action is one to 10 minutes, with peak levels occurring within 30 minutes. There are active metabolites, norketamine and dehydronorketamine, both psychoactive. The half-life is two to three hours. Neurologic effects predominate and include nystagmus, catalepsy, hypertonicity, nonpurposeful movements, dystonic reactions, and bizarre vocalizations. Early cardiovascular effects include a transient increase in blood pressure and heart rate. Dosedependent respiratory depression is seen, along with increased oral secretions. Whereas at anesthetic doses, intact corneal, light, pharyngeal, and laryngeal reflexes are seen, airway crises can occur when higher doses are taken. GHB was initially developed as an anesthetic agent, but enthusiasm for its medical application waned due to lack of any significant analgesic effect and an association with seizure-like clonic activity on emergence. In the United States, GHB entered the health food market in 1990 and was promoted illicitly as a growth hormone releaser, diet aid, sleep aid, and sexual enhancer. Fiftynine reports of serious toxicity and death from GHB use were made to poison centers in the western and southeast United States within a few months of initial marketing. This prompted the Food and Drug Administration (FDA) and the U.S. Department of Justice to take action against its importation, manufacture, distribution, and promotion. To date, more than 5,700 overdoses in 45 states and 65 deaths have been documented by the U.S. Drug Enforcement Agency (DEA). Date rape facilitated by GHB has been reported since 1994, and to date, more than 50 cases have been documented. GHB is metabolized via the Kreb’s cycle to carbon dioxide, which is then expired. The half-life is a short 27 minutes, and the duration of action is two to five hours. Predicting dose response is difficult based on the variability of drug found in one “scoop” (2.8–7.9 gm) of powder or one capful of liquid. Admixture with other substances such as ethanol, known to have a synergistic effect, or use of impure home preparations also contribute to the variable responses seen following a given dose. Nonetheless, the usual illicit dose is 1 to 2.5 gm or one to two capfuls (1 gm/5 ccs). This corresponds to an average dose of 35 mg/kg. Most patients present with a triad of gastrointestinal, respiratory, and neurologic symptoms.

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Early symptoms include somnolence within 15 minutes of an oral dose, dizziness, lightheadedness, and a “high” feeling. Higher doses might be associated with nausea, vomiting, impaired judgment, hallucinations, confusion, ataxia, loss of peripheral vision, and abrupt unconsciousness, generally with doses greater than 60 mg/kg. Intermittent respiratory depression and apnea vacillate with periods of combativeness and aggression. Interestingly, increased aggression in response to direct gaze has been observed. Random clonic movements of the face and extremities might occur. Other findings may include hypothermia, bradycardia, and excessive salivation, relating to the corrosive effects of some home preparations. Regarding management of the date rape victim, White says this type of patient requires “a meticulous physical examination.” She advises the health care provider to gain an accurate time frame of ingestion through interviewing friends or bystanders, and to make early contact with law enforcement. She also suggests the retrieval of containers could be very useful for later analysis. She adds that consent should be obtained for evidence collection, examination, and involvement of authorities: Given the rapid clearance of these drugs, the immediate procurement of samples prior to the use of confounding medications for sedation is important. Above all, chainof-custody must be maintained in the handling of specimens. As with the management of all sexual assault victims, counseling by an experienced professional prior to discharge is advised. Patients who are still lethargic at six hours post-ingestion should be admitted.

White adds that the prosecution of offenders might be difficult because there could be a delay in victim presentation. Furthermore, failure to detect the intoxicant does not prove that it was not used, given the rapid clearance of these agents. Health care providers should be cognizant of the narrow window of opportunity for successfully detecting the date rape drugs. Despite the technology available, Ledray (2001) cautions that “positive results of a blood, urine, or hair specimen are rarely obtained.” She says that law enforcement and prosecutors must rely on the physical evidence as well as the patient history collected by the forensic examiner. Ledray writes, “Because the SANE is conducting a medical examination and can testify in court about what the victim reported during the examination as an exception to the hearsay rule, this testimony can be important corroborating evidence and very useful in court.” To this end, the forensic examiner must carefully and precisely document what the victim says, using the victim’s own words whnever possible. “The victim’s ability to recall past events should also be documented in detail, because the credibility of the victim will often be challenged when the case goes to trial,” Ledray adds. “It is helpful for the SANE

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to note if the victim’s speech is clear, if his or her gait is steady, and if there are any other viable physical signs of intoxication or impairment at the time of the examination.” In many DFSA cases, it is unclear whether a sexual assault took place, and if the victim cannot give an account of the assault, the forensic examiner must conduct a thorough head-to-toe visual examination, looking for areas of redness, swelling, abrasions, bruising, scratches, or cuts, as well as palpate for areas of soreness. The victim’s oral, rectal, and vaginal orifices should be examined for trauma, and specimens should be collected to help determine if recent sexual contact occurred. “It’s important to note that whereas positive specimens will prove that recent sexual contact did occur, negative results without trauma and without sperm or acid phosphatase do not prove that recent sexual contact did not occur,” Ledray writes. Ledray says that the role of the SANE with suspected DFSA includes much more than biologic evidence collection. “The SANE must also ensure that ED staff and other sexual assault resource team members are familiar with the clinical symptom picture that may indicate a possible DFSA so that proper referrals are made for evidence collection and testing,” she says: The SANE must be aware of the unique victim impact issues for DFSA victims and work closely with the rape crisis advocate to ensure that the victim’s counseling needs are met. Self-blame is often an even more pressing issue because the victim cannot assist with the investigation because of his or her missing memory, perhaps even because of a drug he or she took willingly, without knowing that he or she was in danger of being assaulted. The victim’s fear may be more pronounced because the victim does not know who assaulted him or her or even if he or she was assaulted. Furthermore, the assault probably occurred in a place or with people whom he or she considered safe. The victim’s anger at his or her own inability to remember or his or her inability to help the prosecution of the case can be devastating. Unfortunately, memory is usually not recovered in these cases.

6.12 A NATIONAL PROTOCOL FOR HANDLING SEXUAL ASSAULT CASES In September 2004, the U.S. Department of Justice Office on Violence Against Women published A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents, researched and written by consultant Kristin Littel. The 141-page document is an attempt to address a number of issues affecting the care of victims of violence, and to create a framework in which forensic nurses and all health care providers can work to provide exemplary service. The protocol encompasses what it calls “overarching issues” as well as operational issues, and makes practical recommendations based on the pooling of expert knowledge and experience. It is by no means a final

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work, but should be seen as a work in progress, as forensic nurses undoubtedly will continue to challenge its contents, particularly as current thought in health care and medicine evolves, and as new research is produced to substantiate or negate accepted protocol. The following is a summary of the protocol’s overarching and operational issues, with references to sections that provide readers with additional information.

disclose that they have been sexually assaulted should have access to certain services. Recommendations for Health Care Providers and Other Responders to Facilitate Victim-centered Care •

6.12.1 OVERARCHING ISSUES 6.12.1.1 Coordinated Approach A coordinated, multidisciplinary approach to conducting the exam provides victims with access to comprehensive immediate care, helps minimize trauma they might experience, and encourages their use of community resources. Such a response can also enhance public safety by facilitating investigation and prosecution, which increases the likelihood that offenders will be held accountable for their actions. Raising public awareness about the existence and benefits of a coordinated response to sexual assault could lead more victims to disclose the assault and seek help. The following are recommendations for jurisdictions to facilitate a coordinated approach to the exam process: •

• •

Understand the dual purposes of the exam process to address patients’ needs and justice system needs. Addressing patients’ needs might include evaluating and treating injuries; conducting prompt exams; providing support, crisis intervention, and advocacy; providing prophylaxis against STIs and referrals; assessing reproductive health issues; and providing follow-up contact and care. Addressing justice system needs might include obtaining a history of the assault; documenting exam findings; properly collecting, handling, and preserving evidence; and (postexam) interpreting and analyzing findings, presenting findings, and providing factual and expert opinions. Identify key responders and their roles. Develop quality assurance measures to ensure effective immediate response.

•

•

•

•

•

• •

6.12.1.2 Victim-Centered Care Victim-centered care is paramount to the success of the exam process. Response to victims should be timely, appropriate, sensitive, and respectful. Sexual assault patients are also referred to as victims, depending on which responders are primarily being discussed. The term patients is generally used by health care professionals. The term victim is not used in a strictly criminal justice context. The use of victim simply acknowledges that persons who

•

Give sexual assault patients priority as emergency cases and respond in a timely manner. Provide them with as much privacy as possible, while ensuring that they are supported. Recognize that the medical forensic exam is an interactive process that must be adapted to the needs and circumstances of each patient. Be aware of issues commonly faced by victims from specific populations. For example, certain characteristics (e.g., culture, religion, language skills or mode of communication, disabilities, gender, and age) can influence a victim’s behavior in the aftermath of an assault, including the exam process. Understand the importance of victim services within the exam process. Victim service providers and advocates typically offer victims support, crisis intervention, information and referrals, and advocacy to ensure that victims’ interests are represented, their wishes respected, and their rights upheld. Providers and advocates also might offer support for family members and friends who are present. In addition, they can promote sensitive, appropriate, and coordinated interventions. Involve victim service providers and advocates in the exam process as soon after a victim discloses an assault as possible. Victims have the right to accept or decline victim services. Accommodate patients’ requests to have relatives, friends, or other support persons (e.g., a religious or spiritual counselor) present during the exam, unless the presence of that person could be considered harmful. Accommodate victims’ request for responders of a specific gender as much as possible. Prior to starting the exam and before each procedure, describe what is entailed and its purpose to patients. Be sure that communication and language needs are met and information is conveyed in a manner that patients will understand. After providing this information, seek patients’ permission to proceed and respect their right to decline any part of the exam. However, follow exam facility and jurisdictional policy regarding minors and adults who are incompetent to give consent. Assess and respect patients’ priorities.

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•

•

•

•

Integrate exam procedures where possible (e.g., blood samples needed for medical and evidentiary purposes should be drawn at the same time). Address patients’ safety concerns during the exam. Sexual assault patients have legitimate reasons to fear further assaults from their attackers. Local law enforcement might be able to assist facilities in addressing patients’ safety needs. Provide information that is easy for patients to understand and that can be reviewed at their convenience. After the exam is finished, provide patients with the opportunity to wash, change clothes (providing clean replacement clothing if necessary), get food or drinks, and make needed phone calls.

6.12.1.3 Informed Consent Patients should understand the full nature of their consent to each exam procedure. When presented with relevant information, they are in a position to make an informed decision about whether to accept or decline a procedure. However, they should be aware of the impact of declining a particular procedure, as it could negatively affect the quality of care, the usefulness of evidence collection, and, ultimately, any criminal investigation or prosecution. They should understand that declining a particular procedure might also be used to discredit them in court. If a procedure is declined, reasons why should be documented if the patient provides such information. Recommendations for Health Care Providers and Other Responders to Request Patients’ Consent During the Exam Process •

•

Seek informed consent as appropriate throughout the exam process for medical evaluation and treatment, the forensic exam, and evidence collection. Coordinate efforts to obtain consent among responders. Be aware of statutes and policies governing consent in cases of minor patients, vulnerable adult patients, and patients who are unconscious, intoxicated, or under the influence of drugs. In all cases, however, the exam should never be done against the will of the patient.

6.12.1.4 Confidentiality Involved responders must be aware of the scope and limitations of confidentiality related to information gathered during the exam process. Confidentiality is intricately linked to the scope of patients’ consent. Members of a SART or other collaborating responders should inform victims of the scope of confidentiality with each responder

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and be cautious not to exceed the limits of victim consent to share information in each case. Recommendations That Jurisdictions Might Take to Maintain Confidentiality of Patients •

•

•

•

Make sure that jurisdictional policies address confidentiality related to the medical forensic exam (e.g., of forensic documentation, photographs, and colposcopic video images). Increase responders’ and patients’ understanding of confidentiality issues (e.g., scope of confidentiality advocates can provide; scope of confidentiality of information shared with examiners, law enforcement, prosecutors, and other responders with whom patient has contact; and what happens to information once it enters the criminal justice system). Consider the impact of federal privacy laws regarding health information on victims of sexual assault. Strive to resolve intrajurisdictional conflicts.

6.12.1.5 Reporting to Law Enforcement Reporting provides the criminal justice system with the opportunity to offer immediate protection to victims, collect evidence from all crime scenes, investigate cases, prosecute if there is sufficient evidence, and hold offenders accountable for crimes committed. Given the danger that sex offenders pose to the community, reporting can serve as a first step in efforts to stop them from reoffending. Equally important, reporting gives the justice system the chance to help victims address their needs, identify patterns of sexual violence in the jurisdiction, and educate the public about such patterns. It is recommended that service providers encourage victims to report due in part to the recognition that delayed reporting is detrimental to the prosecution and to holding offenders accountable. Victims need to know that even if they are not ready to report at the time of the exam, the best way to preserve their option to report later is to have the exam performed. Reporting requirements in sexual assault cases vary from one jurisdiction to another. Every effort should be made to facilitate treatment and evidence collection (if the patient agrees), regardless of whether the decision to report has been made at the time of the exam. Victims who are undecided about reporting who receive respectful and appropriate care and advocacy at the time of their exam are more likely to assist law enforcement and prosecution. Recommendations for Jurisdictions and Responders to Facilitate Victim-centered Reporting Practices •

Where permitted by law, patients, not health care workers, should make the decision to report a sexual assault to law enforcement. Patients

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•

•

•

should be provided with information about possible benefits and consequences of reporting so that they can make an informed decision. It is not recommended to require reporting as a condition of performing or paying for the exam. Even if patients are undecided about reporting, they should be encouraged to provide a medical forensic history, undergo the forensic exam, and have evidence collected and stored. Jurisdictions might want to consider alternatives to standard reporting procedures. For example, an anonymous or blind reporting system might be useful in cases in which victims do not want to report immediately or are undecided about reporting. Jurisdictions should consider a variety of approaches that promote a victim-centered reporting process.

6.12.1.6 Payment for the Examination Under the VAWA Under the Violence Against Women Act (VAWA), a state, territory, or the District of Columbia is entitled to funds under the STOP Violence Against Women Formula Grant Program only if it, or another governmental entity, incurs the full out-of-pocket cost of medical forensic exams for victims of sexual assault. The VAWA provisions indicate the exam should minimally include “an examination of physical trauma; determination of penetration/force; a victim interview; and collection and evaluation of evidence.” Full out-of-pocket costs means any expense that can be charged to a victim in connection with the exam for the purpose of gathering evidence of a sexual assault. Recommendations for Jurisdictions to Facilitate Payment for the Sexual Assault Medical Forensic Exam • •

Understand the scope of the VAWA provisions related to exam payment. Ensure that victims are notified of exam facility and jurisdictional policies regarding payment for medical care and the medical forensic exam, as well as if and how reporting decisions will impact payment. Relevant government entities are strongly encouraged to pay for medical forensic exams regardless of whether victims pursue prosecution.

6.12.2 OPERATIONAL ISSUES 6.12.2.1 Sexual Assault Forensic Examiners These are the health care professionals who conduct the examination. It is critical that all examiners, regardless of

their discipline, are committed to providing compassionate and quality care for patients disclosing sexual assault, collecting evidence competently, and testifying in court as needed. Recommendations for Jurisdictions to Build the Capacity of Examiners Performing These Exams • •

Encourage the development of specific examiner knowledge, skills, and attitudes. Encourage advanced education and supervised clinical practice of examiners, as well as certification for nurses who are examiners.

6.12.2.2 Facilities Health care facilities have an obligation to provide services to sexual assault patients. Designated exam facilities or sites served by specially educated and clinically prepared examiners increase the likelihood of a state-of-theart exam, enhance coordination, encourage quality control, and increase quality of care for patients. Recommendations for Jurisdictions to Build Capacity of Health Care Facilities to Respond to Sexual Assault Cases • •

•

•

•

Recognize the obligation of health care facilities to serve sexual assault patients. Ensure that exams are conducted at sites served by specially educated and clinically prepared examiners. A designated facility can employ or have ready access to examiners to conduct the exam. Some jurisdictions have examiner programs that serve one or multiple exam sites within a specific area. Explore what is best for the community regarding locations for exam sites. It is critical to consider how accessible facilities are to patients disclosing sexual assault, as well as the facility’s capacity to properly conduct these exams and treat related injuries. Recognize that exam facilities and examiners could benefit from networking with examiners in other facilities or areas for support with peer review of medical forensic reports, quality assurance, and information sharing (e.g., on training opportunities, practices, and referrals for patients). Consider developing basic jurisdictional requirements for exam sites. The analysis of evidence gathered during the examination, along with examiner documentation of findings, could help in determining whether penetration occurred or force was used. However, examiners are not responsible for drawing conclusions

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about how injuries were caused or whether the assault occurred or not (although they can note consistency between patients’ statements and injuries they identify). Promote public awareness about where exams are conducted. Use specially educated and clinically prepared forensic examiners to conduct the exam, ensuring dissemination of relevant information to appropriate agencies and community members. Encourage first responders to work together to assist victims in using these sites. If a transfer from one health care facility to a designated site is necessary, use an established protocol that minimizes time delays and loss of evidence while addressing a patient’s needs. However, avoid transferring these patients whenever possible.

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not limited to clothing, foreign materials on the body, hair (including head and pubic hair samples and combings), oral and ano-genital swabs and smears, body swabs, and a blood or saliva sample for DNA analysis and comparison. The instruction sheet or checklist should guide examiners on maintaining the chain of custody for evidence collected. Recommendations for Jurisdictions and Responders When Developing or Customizing Kits •

• •

6.12.2.3 Equipment and Supplies Certain equipment and supplies are essential to the exam process (although they might not be used in every case). These include a copy of the most current exam protocol used by the jurisdiction, standard exam room equipment and supplies, comfort supplies for patients, sexual assault evidence collection kits, an evidence drying device or method, a camera, testing and treatment supplies, an alternate light source, an anoscope, and written materials for patients. A microscope and toluidine blue dye might be required, depending on jurisdictional policy. A colposcope or other magnifying instrument is strongly suggested. Some jurisdictions are also beginning to use advanced technology (telemedicine), which allows examiners to conduct offsite consultation with medical experts using computers, software programs, and the Internet. Recommendations for Jurisdictions and Responders to Ensure that Proper Equipment and Supplies Are Available for Examinations • •

Consider what equipment and supplies are essential. Address cost barriers to obtaining equipment and supplies.

Use standardized kits (across a local jurisdiction, region, state, territory, or tribal land) that meet or exceed minimum guidelines for contents, as described previously. Make kits readily available at any facility that conducts sexual assault medical forensic exams. Periodically review the kit’s efficiency and usefulness and make changes as needed.

6.12.2.5 Timing Considerations for Collecting Evidence Although many jurisdictions currently use 72 hours after the assault as the standard cutoff time for collecting evidence, evidence collection beyond that point is conceivable. Because of this, some jurisdictions have extended the standard cutoff time (e.g., to five days or one week). Advancing DNA technologies continue to extend time limits because of the stability of DNA and sensitivity of testing. These technologies are even enabling forensic scientists to analyze evidence that was previously unusable when it was collected years ago. Thus, it is critical that in every case in which patients are willing, examiners obtain the medical forensic history, examine patients, and document findings. Not only can the information gained from the history and exam help health care providers address patients’ medical needs, but it can guide examiners in determining whether there is evidence to collect and, if so, what to collect. Recommendations for Health Care Providers and Other Responders to Maximize Evidence Collection

6.12.2.4 Sexual Assault Evidence Collection Kit

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Most jurisdictions have developed their own sexual assault evidence collection kits or purchased premade kits through commercial vendors. Kits often vary from one jurisdiction to another. Despite variations, however, it is critical that every kit meets or exceeds minimum guidelines for contents: broadly including a kit container, instruction sheet or checklist, forms, and materials for collecting and preserving all evidence required by the applicable crime laboratory. Evidence that might be collected includes but is

•

•

Whether or not evidence is collected, examiners should obtain the medical forensic history as appropriate, examine patients, and document findings (with patients’ consent). Patients’ demeanor and statements related to the assault should also be documented. Promptly examine patients to minimize loss of evidence and to identify medical needs and concerns. Decide whether to collect evidence and what to collect on a case-by-case basis, remembering

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•

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that outside time limits for obtaining evidence vary. In any case, where the need for evidence collection is in question, encourage dialogue about the potential benefits or limitations of collection. Avoid basing decisions about whether to collect evidence on a patient’s characteristics or circumstances (e.g., the patient has used illegal drugs). Responders should seek education and resources that aid them in making well-informed decisions about evidence collection.

6.12.2.6 Evidence Integrity

assistance to victims. Communities need to have procedures in place to promptly respond to disclosures and reports of sexual assault in a standardized and victimcentered manner. Recommendations for Jurisdictions and Responders to Facilitate Initial Contact with Victims •

•

Properly collecting, preserving, and maintaining the chain of custody of evidence is critical to its subsequent use in criminal justice proceedings. Recommendations for Health Care Providers and Other Responders to Maintain Evidence Integrity • •

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Follow jurisdictional policies for drying, packaging, labeling, and sealing the evidence. Follow jurisdictional policies for documenting exam findings, the medical forensic history, and the patient’s demeanor and statements, and packaging, labeling, and sealing such documentation. Follow jurisdictional policies for consistent evidence management and distribution. A duly authorized agent should transfer evidence from the exam site to the appropriate crime lab or other designated storage site (e.g., a law enforcement property facility). Make sure storage procedures maximize evidence preservation. Ensure that storage areas are kept secure and at the proper temperature for the evidence. Also, make sure jurisdictional policies are in place to address the secure storage of evidence in cases in which patients are undecided about reporting. Maintain the chain of custody of evidence. All those involved in handling, documenting, transferring, and storing evidence should be educated regarding the specifics of their roles in properly preserving evidence and maintaining the chain of custody.

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6.12.2.8 Triage and Intake Once patients arrive at the exam site, health care personnel must evaluate, stabilize, and treat them for life-threatening and serious injuries according to facility policy. Standardized procedures for response in these cases should be followed, while respecting patients and maximizing evidence preservation. Recommendations for Health Care Providers to Facilitate Triage and Intake that Addresses Patients’ Needs •

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6.12.2.7 The Examination Process Some sexual assault patients might initially present at a designated exam facility, but most who receive immediate medical care initially contact a law enforcement or advocacy agency for help. If 911 is called, law enforcement or emergency medical services might be the first to provide

Build consensus among involved agencies regarding procedures for a coordinated initial response when a recent sexual assault is disclosed or reported, and educate responders on procedures. Encourage victims to interact with advocates as soon after disclosure as possible. Recognize essential elements of initial response. In particular, encourage victims to seek medical care and have evidence collected. In the case of life-threatening or serious injuries, obtain emergency medical assistance according to jurisdictional policy. Any life-threatening wounds should be treated and victims’ immediate safety needs should be addressed before evidence is collected. If victims decide to seek medical care, have evidence collected, or both, follow jurisdictional policies for preserving evidence, collecting a urine sample if needed, and transporting victims to the exam site.

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Consider sexual assault patients a priority. Use private locations in the exam facility for the primary patient consultation and initial law enforcement interviews, offer a waiting area for family members and friends, and provide child care if possible. Respond to acute injury, trauma care, and safety needs of patients before collecting evidence. Patients should not wash, change clothes, urinate, defecate, smoke, drink, or eat until initially evaluated by examiners, unless necessary for treating acute medical needs. Alert examiners to the need for their services at the exam site.

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• •

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Contact victim advocates so they can offer services to the patient, if not already done. Assess and respond to safety concerns, such as threats to the patient or staff, on arrival of patients at the exam site. Assess patients’ needs for immediate medical or mental health intervention. Seek informed consent from patients before providing treatment, according to facility policy.

6.12.2.9 Documentation by Health Care Personnel Examiners document exam findings, the medical forensic history, and evidence collected in the medical forensic report. Examiners and other involved clinicians separately document medical care in the patient’s medical record.

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Recommendations for Health Care Providers to Complete Needed Documentation •

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Ensure completion of all appropriate documentation. The forensic details of the exam are documented in the medical forensic report, according to jurisdictional policy. The only medical issues documented in this report are acute findings that potentially relate to the assault or preexisting medical factors that could influence interpretation of findings. Separate medical documentation by examiners and other involved clinicians follows a standard approach—address acute complaints, gather pertinent historical data, describe findings, and document treatment and follow-up care. Ensure the accuracy and objectivity of medical forensic reports by seeking education on proper report writing.

6.12.2.11 Photography Photographic evidence of injury on the patient’s body can supplement the medical forensic history and document physical findings. Recommendations for Health Care Providers and Other Responders to Photograph Evidence •

6.12.2.10 The Medical Forensic History Examiners ask the patient questions to obtain this history. This information guides them in examining the patient and collecting evidence.

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Recommendations for Health Care Providers to Facilitate Gathering Information from Patients •

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Examiners should coordinate with other responders, primarily law enforcement representatives, to facilitate information gathering that is respectful to patients and minimizes repetition of questions. Keep in mind that advocates can support and advocate for patients when the medical forensic history is taken (if desired by patients), but they cannot actively participate in the process. Patients should be informed that the presence

of family members, friends, and others offering personal support during this time might influence or be perceived as influencing their statements. If patients choose to have others present despite this knowledge, these individuals should not actively participate in the process. Consider and address patients’ needs prior to information gathering, including identifying the level of their communication skill and modalities and then tailoring information gathering accordingly. Obtain the medical forensic history in a private, quiet setting. Gather information for the history according to jurisdictional policy. Include the date and time of the assault, pertinent patient medical history (e.g., menstruation history), recent consensual sexual activity of the patient, the patient’s activities since the assault (e.g., took a shower), the patient’s assault-related history (e.g., loss of consciousness), suspect information if known (e.g., number and gender of assailants), nature of the physical assault, and description of the sexual assault.

•

Come to a consensus about the extent of forensic photography necessary. Some jurisdictions routinely take photographs of both detected injuries on patients and normal (apparently uninjured) anatomy, whereas others limit photography to detected injuries. Consider who will take photographs and what equipment will be used. Photographers should be familiar with equipment operation and educated in forensic photography and in ways to maintain the patient’s privacy and dignity while taking photographs. Consult with jurisdictional criminal justice agencies and examiners regarding the type of equipment that should be used. Obtain informed consent from patients before taking photographs. Patients should understand the purpose of the photographs, what will be photographed and any related procedures, the potential uses of photographs during investigation and prosecution, and the possible need for follow-up photographs.

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Consider the patient’s comfort and need for modesty. Identify who will be present when photographs are taken. Take initial and follow-up photographs as appropriate, according to jurisdictional policy.

6.12.2.12 Exam and Evidence Collection Procedures Examiners examine patients and collect evidence according to jurisdictional policy. Findings from the exam and collected evidence often help reconstruct the events in question in a scientific and objective manner.

how to screen for suspected drug-facilitated sexual assault, obtain informed consent of patients for testing, and collect toxicology samples when needed. Recommendations for Jurisdictions and Responders to Facilitate Response in Suspected Drug-facilitated Sexual Assault •

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Recommendations for Health Care Providers to Conduct the Exam and Facilitate Evidence Collection •

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Strive to collect as much evidence from patients as possible, considering the scope of informed consent, the medical forensic history, the examination, and evidence collection kit instructions. Be aware of evidence that might be pertinent to the issue of whether the patient consented to sexual contact with the suspect. Understand how biological evidence is tested. Prevent exposure (of both patients and staff) to infectious materials and contamination of evidence. Understand the implication of the presence or lack of semen (in cases involving male suspects). Seek informed consent from patients for each portion of the exam and evidence collection. Modify the exam and evidence collection to address the specific needs and concerns of patients. Conduct the general physical and ano-genital examination, guided by the scope of informed consent and the medical forensic history. Document findings on body diagram forms. With the patient’s consent, use an alternate light source, colposcope, and anoscope, as appropriate and if available, to increase the likelihood of detecting evidence. Collect evidence to submit to the crime lab for analysis, according to jurisdictional policy. Collect blood and urine for toxicology screening, if applicable. Keep medical specimens separate from forensic specimens collected during the exam.

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Educate examiners, 911 dispatchers, law enforcement representatives, prosecutors, judges, and advocates on related issues. Develop jurisdictional policies to clarify first responders’ roles in cases involving suspected drug-facilitated assault. Be clear about the circumstances in which toxicology testing might be indicated (for optimal care or when there is a suspicion of drug-facilitated sexual assault). Routine toxicology testing in all sexual assault cases is not recommended. Informed consent of patients should be sought to collect toxicology samples. Patients should be aware of the purposes and scope of testing that will be done, potential benefits and consequences of testing, any follow-up treatment necessary, how they can obtain results, who will pay for the testing, and if they have any opportunity to revoke consent to testing. With patients’ permission, immediately collect a urine specimen if it is suspected that ingestion of drugs used to facilitate sexual assault occurred within 96 hours prior to the exam. The first available urine should be collected; law enforcement and emergency medical services should be trained and prepared to collect a urine sample if patients must urinate prior to arrival at the health care facility for the exam. Advocates and other professionals who might have contact with patients prior to their arrival at the exam site should also be educated to provide those who suspect drug-facilitated assault with information on how to collect a sample if the patient cannot wait to urinate until getting to the site. Collect a blood sample if it is suspected that the ingestion of drugs used to facilitate sexual assault occurred within 24 hours of the exam. If a blood alcohol determination is needed, collect blood within 24 hours of ingestion of alcohol, according to jurisdictional policy. Jurisdictional policies should be in place and followed for packaging, storing, and transferring samples.

6.12.2.13 Drug-Facilitated Sexual Assault

6.12.2.14 STI Evaluation and Care

Responders must consider the possibility that drugs might have been used to facilitate an assault. They must know

Because contracting an STI from an assailant is of significant concern to patients, it should be addressed during the exam.

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Recommendations for Health Care Providers to Facilitate STI Evaluation and Care •

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•

•

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Offer patients information about the risks of STIs (including HIV), the symptoms and what to do if symptoms occur, testing and treatment options, follow-up care, and referrals. Referrals should include free and low-cost testing, counseling, and treatment available in various sections of the community. For HIV testing, confidential and anonymous testing is recommended. Consider testing patients for STIs during the initial exam on a case-by-case basis. If testing is done, follow the guidelines of the CDC. Encourage patients to accept prophylaxis against STIs during the initial exam. (Note, however, that treatment might not be appropriate for some individuals—for example, if they have a condition that could be adversely affected by taking prophylaxis.) The CDC suggests a regimen to protect against chlamydia, gonorrhea, trichomonas, and bacterial vaginosis, as well as the hepatitis B virus. If accepted, provide care that meets or exceeds CDC guidelines. If declined, it is medically prudent to obtain cultures and arrange for a follow-up exam and testing. Seek informed consent from patients for treatment, according to facility policy. Encourage and facilitate follow-up STI examinations, testing, immunizations, and treatment as directed. Offer postexposure prophylaxis for HIV to patients at high risk for exposure, particularly when it is known that suspects have HIV/AIDS. Meet or exceed CDC recommendations. Discuss risks and benefits of the prophylaxis with patients prior to their decisions to accept or decline treatment. Careful monitoring and follow-up by a health care provider or agency experienced in HIV issues is required.

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6.12.2.16 Discharge and Follow-Up Health care personnel have specific tasks to accomplish before discharging patients, as do advocates and law enforcement representatives (if involved). Responders should coordinate discharge and follow-up activities as much as possible to reduce repetition and avoid overwhelming patients. Recommendations to Facilitate Discharge and Follow-up •

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6.12.2.17 Examiner Court Appearances Health care providers conducting the exam should expect to be called on to testify in court as fact or expert witnesses. Recommendations for Jurisdictions to Maximize the Usefulness of Examiner Testimony in Court •

6.12.2.15 Pregnancy Risk Evaluation and Care Female patients might fear becoming pregnant as a result of an assault. Health care providers must address this issue according to facility and jurisdictional policy. Recommendations for Health Care Providers to Facilitate Pregnancy Evaluation and Care • • •

Discuss the probability of pregnancy with patients. Administer a baseline pregnancy test for all patients with reproductive capability. Discuss treatment options with patients, including reproductive health services.

It is important to ensure that patients are fully informed about postexam care. Information might include referrals to other professionals to make sure that patients’ medical and mental health needs related to the assault have been addressed, discharge instructions, follow-up appointments with the examiner or other health care providers, and contact procedures for medical follow-up. In addition to medical followup, follow-up might be indicated to document developing or healing injuries and complete resolution of healing. Advocates and law enforcement representatives, if involved, should coordinate with examiners to discuss other issues with patients, including planning for their safety and wellbeing, physical comfort needs, information needs, the investigative process, advocacy and counseling options, and law enforcement and advocacy follow-up contact procedures.

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Encourage broad education for examiners on testifying in court. Promote prompt notification of examiners if there is a need for them to testify in court. Encourage pretrial preparation of examiners. Encourage examiners to seek feedback on testimony to improve effectiveness of future court appearances.

REFERENCES Abbott, J., Feldhaus, K. M., Houry, D., & Lowenstein, S. R. Emergency contraception: What do our patients know? Ann Emerg Med. 43, 3, 376–381, 2004.

186

Acosta, M. L. Collecting evidence for domestic and sexual assault: Highlighting violence against women in health care system intervention. International J Gynaecology and Obstetrics. 78(Suppl. 1), S99–S104, 2002. Adams, J. A. Evolution of a classification scale: Medical evaluation of suspected child sexual abuse. Child Maltreatment. 6, 31–36, 2001. Adams, J. A., Girardin, B., & Faugno, D. Signs of genital trauma in adolescent rape victims examined acutely. J Pediatr Adolesc Gynecol. 13, 2, 88, 2000. American College of Emergency Physicians (ACEP). Evaluation and management of the sexually assaulted or sexually abused patient. Washington, DC: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1999. Amey, A. L., & Bishai, D. Measuring the quality of medical care for women who experience sexual assault with data from the National Hospital Ambulatory Medical Care Survey. Annals of Emergency Medicine. 39, 631–663, 2002. Anglin, D., Spears, K. L., Hutson, H. R. Flunitrazepam and its involvement in date or acquaintance rape. Acad Emerg Med. 4, 323–326, 1997. Antognoli-Toland, P. Comprehensive program of examination of sexual assault victims: A hospital-based project in Texas. J Emerg Nurs. 11, 3, 132–135, 1985. Arndt, S. Nurses help Santa Cruz sexual assault survivors. California Nurse. 84, 8, 4–5, 1988. Bell, K. How are emergency departments using sexual assault nurse examiners (SANEs) within the ED routine? J Emerg Nurs. 24, 6, 440, 1998. Biggs, M., Stermac, L. E., & Divinsky, M. Genital injuries following sexual assault of women with and without prior sexual experience. Canadian Medical Association Journal. 159, 33–37, 1998. Blair, T., & Warner, C. Sexual assault. Topics in Emergency Medicine, 14, 4, 58–77, 1992. Bobak, I. M. Violence against women. In Maternity & Gynecologic Care St. Louis: Mosby. 1992. Bownes, I., Gorman, E., & Saters, A. A rape comparison of stranger and acquaintance assaults. Medical Science Law. 31, 2, 102–109, 1991. Bowyer, L., & Dalton, M. Female victims of rape and their genital injuries. Br J Obstet Gynaecol. May, 104, 5, 617–620, 1997. Breslau, N., Davis, G. C., Andreski, P., & Petersen, E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry. 48, 216–222, 1991. Burgess, A. W., Fawcett, J., Hazelwood, R. R., & Grant, C. A. Victim care services and the comprehensive sexual assault assessment tool. In R. R. Hazelwood & A. W. Burgess, Eds., Rape Investigation (pp. 263–281). New York: CRC Press. 1995. Burnam, M. A, Stein, J. A., & Golding, J. M. Sexual assault and mental disorders in a community population. J Consult Clin Psychol. 56, 843–850, 1988. Buss, T. F., Abdu, R., & Walker, J. R. Alcohol, drugs, and urban violence in a small city trauma center. J Substance Abuse Treatment. 12, 2, 75–83, 1995.

Forensic Nursing

Campbell, J. C. Health consequences of intimate partner violence. The Lancet. 359, 1331–1336, 2002. Campbell, R. The effectiveness of sexual assault nurse examiner programs. Violence Against Women Online Resources. www.vawnet.org. November 2004. CDC. CDC issues updated guidelines on use of antiretroviral drugs to prevent HIV infection after sexual, drug use, and accidental exposure. Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention. www.cdc.gov. Jan. 20, 2005. Centers for Disease Control and Prevention. Sexual assault and STDs: Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. May 10, 51(RR-6), 69–74, 2002. Chaudhry, S. Retrospective study of alleged sexual assault at the Aga Khan Hospital, Nairobi. East African Medical Journal. 72, 200–202, 1995. Cherpitel, C. J. Alcohol and violence-related injuries: An emergency room study. Addiction. 88, 1, 79–88, 1993. Ciancone, A. C., Wilson, C., & Collette, R. Sexual assault nurse examiner programs in the United States. Ann Emerg Med. April, 35, 4, 353–357, 2000. Cohen, L., Donohue, J., & Kovener, M. A SANE approach to treating sexual assault survivors in Colorado: Utilizing sexual assault nurse examiners. Denver: Colorado Coalition Against Sexual Assault. 1996. Cohen, S., de Vos, E., & Newberger, E. Barriers to physician identification and treatment of family violence: Lessons from five communities. Academic Medicine. 72 (Suppl. 1), S19–S25, 1997. Cornell, D. Helping victims of rape: A program called SANE. New Jersey Medicine. 2, 45–46, 1998. Crandall, C., & Helitzer, D. Impact Evaluation of a Sexual Assault Nurse Examiner (SANE) Program (NCJ 203276). Washington, DC: National Institute of Justice. 2003. Crowley, S. R. Sexual assault: The medical legal examination. New York: McGraw-Hill. 1999. Crowley, S. R. Sequential methodology for the examination of sexual homicide victims. J Forensic Sciences, 50, 1, 2005. Dansky, B. S., Brewerton, T. D., Kilpatrick, D. G., & O’Neil, P. M. The National Women’s Study: Relationship of crime victimization and PTSD to bulimia nervosa. Int J Eat Disord. 21, 213–228, 1997. Derhammer, F., Lucente, V., Reed, J. F., & Young M. J. Using a SANE interdisciplinary approach to care of sexual assault victims. Jt Comm J Qual Improv. August, 26, 8, 488–496, 2000. DiNitto, D., Martin, P. Y., Norton, D. B., & Maxwell, M. S. After rape: Who should examine rape survivors? American J Nursing. 86, 5, 538–540, 1986. Du Mont, J., & Parnis, D. Sexual assault and legal resolution: Querying the medical collection of forensic evidence. Med Law. 19, 4, 779–792, 2000. Du Mont, J., & Parnis, D. Forensic nursing in the context of sexual assault: Comparing the opinions and practices of nurse examiners and nurses. Appl Nurs Res. August, 16, 3, 173–183, 2003.

Sexual Assault

Du Mont, J., & Parnis, D. The doctor’s dilemma: Caregiving and medicolegal evidence collection. Med Law. 23, 3, 515–529, 2004. Eckert, L. O., Sugar, N., & Fine, D. Factors impacting injury documentation after sexual assault: Role of examiner experience and gender. Am J Obstet Gynecol. 190, 6, 1739–1746, 2004. Elliott, D. M., Mok, D. S., & Briere, J. Adult sexual assault: Prevalence, symptomatology, and sex differences in the general population. J Trauma Stress. 17, 3, 203–211, 2004. Ericksen, J., Dudley, C., McIntosh, G., Ritch, L., Shumay, S., & Simpson, M. Clients’ experiences with a specialized sexual assault service. J Emerg Nurs. 28, 1, 86–90, 2002. Falsetti, S. A., Lydiard, R. B., Gibbs, N., & Resnick, H. S. Irritable bowel syndrome: Associations with psychiatric disorders, victimization, and health care seeking behavior. Paper presented at the Anxiety Disorders Association of America (ADAA), New Orleans, LA. 1997. Feldhaus, K. M., Houry, D., & Kaminsky, R. Lifetime sexual assault prevalence rates and reporting practices in an emergency department population. Ann Emerg Med. 36, 1, 23–27, 2000. Frank, C. The new way to catch rapists. Redbook, December, 61–65, 1996. Frazier, P. A., & Haney, B. Sexual assault cases in the legal system: Police, prosecutor, and victim perspectives. Law and Human Behavior. 20, 607–628, 1996. Galvin, J., & Polk, K. Attrition in case processing: Is rape unique? J Research in Crime and Delinquency. 20, 106–154, 1982. Geist, R. F. Sexually related trauma. Emerg Med Clin North Am. 6, 3, 439–466, Aug. 1988. Gibb, A. M., McManus, T., & Forster, G. E. Should we offer antibiotic prophylaxis post sexual assault? Int J STD AIDS. 14, 2, 99–102, 2003. Girardin, B., Faugno, D., Seneski, P., & Slaughter, L. Findings in sexual assault and consensual intercourse. In M. Whelan, Ed., Color Atlas of Sexual Assault (pp. 19–65). St. Louis, MO: CV Mosby. 1997. Golding, J. M., Stein, J. A., Siegel, J. M., Burnam, M. A., & Sorenson, S. B. Sexual assault history and use of health and mental health services. Am J Community Psychol. 6, 625–644, 1988. Goodman, L. A., Koss, M. P., & Russo, N. F. Violence against women: Physical and mental health effects. Part I: Research findings. Applied and Preventive Psychol. 2, 79–89, 1993. Gray-Eurom, K., Seaberg, D. C., & Wears, R. L. The prosecution of sexual assault cases: Correlation with forensic evidence. Ann Emerg Med. 39, 1, 39–46, 2002. Greenfeld, L. Sex Offenses and Offenders. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics, Office of Justice Programs. NCJ 163392. 1997. Greenwood, M. D. Community cooperatives combat sexual assault and domestic violence. Emerg Med Serv. 32, 2, 60–61, 2003. Grossin, C., Sibille, I., Lorin de la Grandmaison, G., Banasr, A., Brion, F., & Durigon, M. Analysis of 418 cases of sexual assault. Forensic Sci Int. 131, 2–3, 125–130, 2003.

187

Groth, A. N., & Burgess, A. W., Hartman, C. R., & Holstrom, L. L. Rape violence. Available at: www.NursingSpectrum.com Harlow, L. L., Quina, K., Morokoff, P. J., Rose, J. S., & Grimley, D. M. HIV risk in women: A multifaceted model. J Appl Behav Res. 1, 3–38, 1993. Hatmaker, D. D., Pinholster, L., & Saye, J. J. A communitybased approach to sexual assault. Public Health Nurs. 19, 2, 124–127, 2002. Hohenhaus, S. SANE legislation and lessons learned: Sexual assault nurse examiner. J Emerg Nurs. 24, 5, 463–464, 1998. Holloway, M., & Swan, A. A & E management of sexual assault. Nursing Standard. 7, 45, 31–35, 1993. Holmes, M. Sexually transmitted infections in female rape victims. AIDS Patient Care STDS. 13, 12, 703–708, 1999. Holmes, M. M., Resnick, H. S., & Frampton, D. Follow-up of sexual assault victims. Am J Obstet Gynecol. 179, 2, 336–342, 1998. Holmes, M. M., Resnick, H. S., Kilpatrick, D. G., & Best, C. L. Rape-related pregnancy: Estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 175, 320–325, 1996. Houry, D., Feldhaus, K. M., & Nyquist, S. R. Emergency department documentation in cases of intentional assault. Ann Emerg Med. 34, 6, 715–719, 1999. Houry, D., Sachs, C. J., Feldhaus, K. M., & Linden, J. Violenceinflicted injuries: Reporting laws in the 50 states. Ann Emerg Med. 39, 1, 56–60, 2002. Hutson, L. A. Development of sexual assault nurse examiner programs. Emergency Nursing. 37, 79–88, 2002. International Association of Forensic Nurses. Sexual Assault Nurse Examiner Standards of Practice. Thorofare, NJ: Slack, Inc. 1996. Irwin, C., Falsetti, S. A., Lydiard, R. B., Ballenger, J. C., Brock, C. D., & Brener, W. Co-morbidity of posttraumatic stress disorder and irritable bowel syndrome. J Clin Psychiatry. 57, 12, 576–578, 1996. Joint Commission on Accreditation of Health Organizations. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health Care Organization. 1997. Jones, J. S., Dunnuck, C., Rossman, L., Wyn, B. N., & NelsonHoran, C. Significance of toluidine blue positive findings after speculum examination for sexual assault. Am J Emerg Med. 22, 3, 201–203, 2004. Jurkovich, G. J., Rivara, F. P., Gurney, J. G., Seguin, D., Fligner, C. L., & Copass, M. Effects of alcohol intoxication on the initial assessment of trauma patients. Ann Emerg Med. 21, 6, 704–708, 1992. Keshavarz, R., Merchant, R. C., & McGreal, J. Emergency contraception provision: A survey of emergency department practitioners. Acad Emerg Med. 9, 1, 69–74, 2002. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 52, 1048–1060, 1995. Kiecolt-Glaser, J., & Glaser, R. Psychoneuroimmunology: Can psychological interventions modulate immunity? J Consult Clin Psychol. 604, 4, 569–575, 1992.

188

Kilpatrick, D., Edmunds, C., & Seymour, A. Rape in America: A Report to the Nation. Arlington, VA: National Victim Center. 1992. Kilpatrick, D. G., Saunders, B. E., Veronen, L. J., Best, C. L., & Von, J. M. Criminal victimization: Lifetime prevalence, reporting to police, and psychological impact. Crime and Delinquency. 334, 479–489, 1987. Kimerling, R., & Calhoun, K. S. Somatic symptoms, social support, and treatment seeking among sexual assault victims. J Consult Clin Psychol. 62, 333–340, 1994. Kintz, P., Villain, M., & Ludes, B. Testing for the undetectable in drug-facilitated sexual assault using hair analyzed by tandem mass spectrometry as evidence. Ther Drug Monit. 26, 2, 211–214, 2004. Koss, M. P., & Heslet, L. Somatic consequences of violence against women. Arch Family Med. 1, 53–59, 1992. Koss, M. P., Koss, P. G., & Woodruff, W. J. Deleterious effects of criminal victimization on women’s health and medical utilization. Arch Intern Med. 151, 342–347, 1991. Koss, M. P., Woodruff, W. J., & Koss, P. G. Relation of criminal victimization to health perceptions among women medical patients. J Consult Clin Psychol. 58, 147–152, 1990. LaFree, G. Variables affecting guilty pleas and convictions in rape cases: Toward a social theory of rape processing. Social Forces. 58, 833–850, 1980. Lang, K. S. Sexual assault nurse examiner resource guide for Michigan communities. Okemos, MI: Michigan coalition against domestic and sexual violence. 1999. Langan, P. A., & Farrington, D. P. Crime and justice in the United States and in England and Wales, 1981–96. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. NCJ 169284. 1998. Laws, A., & Golding J. M. Sexual assault history and eating disorder symptoms among White, Hispanic, and African-American women and men. Am J Public Health. 86, 579–581, 1996. Ledray, L. E. The sexual assault examination: Overview and lessons learned in one program. J Emer Nurs. 18, 3, 223–230, 1992a. Ledray, L. E. The sexual assault nurse clinician: A 15-year experience in Minneapolis. J Emer Nurs. 18, 3, 217–222, 1992b. Ledray, L. E. Sexual Assault Nurse Examiner (SANE) Development & Operation Guide. Minneapolis, MN: U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime. NCJ 170609. 1999. Ledray, L. E. Forensic Evidence Collection and Care of the Sexual Assault Survivor: The SANE Response. Washington, DC: U.S. Department of Justice, Office of Justice Programs. Violence Against Women Online Resources. 2001. Ledray, L. E., & Barry, L. SANE expert and factual testimony. J Emerg Nurs. 24, 3, 284–287, 1998. Ledray, L. E., Faugno, D., & Speck, P. Sexual assault: Clinical issues. SANE: Advocate, forensic technician, nurse? J Emerg Nurs. 27, 1, 91–93, 2001. Ledray, L. E., & Simmelink, K. Efficacy of SANE evidence collection: A Minnesota study. J Emerg Nurs. 23, 1, 75–77, 1997.

Forensic Nursing

Lenehan, G. P. A SANE way to care for rape victims. J Emerg Nurs. 17, 1, 1–2, 1991. Leserman, J. Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: The impact on subsequent health care visits. Psychological Medicine. 28, 417–425, 1998. Lewis, C. M., DiNitto, D., Nelson, T. S., Just, M. M., & Campbell-Ruggaard, J. Evaluation of a rape protocol: A fiveyear follow-up with nurse managers. J Am Acad Nurse Pract. 15, 1, 34–39, 2003. Lincoln, C. Genital injury: Is it significant? A review of the literature. Med Sci Law. 41, 3, 206–216, 2001. Littel, K. SANE Programs: Improving the Community Response to Sexual Assault Victims. OVC Bulletin. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime. 2001. Litz, B. T., Keane, T. M., & Fisher, L. Physical health complaints in combat-related post-traumatic-stress disorder: A preliminary report. J Traumatic Stress. 5, 1, 131–141, 1992. Lynch, V. A. Forensic nursing: Diversity in education and practice. J Psychosocial Nursing. 132, 3, 7–14, 1993. Malloy, M. Relationship of nurse identified therapeutic techniques to client satisfaction reports in a crisis program. Unpublished master’s thesis, University of Minnesota, Minneapolis, MN. 1991. Mancino, P., Parlavecchio, E., Melluso, J., Monti, M., & Russo, P. Introducing colposcopy and vulvovaginoscopy as routine examinations for victims of sexual assault. Clin Exp Obstet Gynecol. 30, 1, 40–42, 2003. Marchbanks, P., Lui, K. J., & Mercy, J. Risk of injury from resisting rape. American J Epidemiology. 132, 3, 501–505, 1990. Maxwell, M. S., & Soubielle, K. Hospital sexual assault needs, issues and recommendations: Sexual assault needs assessment. Florida. 57–68, 1996. McFarlane, A. C., Atchison, M., Rafalowicz, E., & Papay, P. Physical symptoms in post-traumatic stress disorder. J Psychosom Res. 38, 715–726, 1994. McGinnis, M., & Foege, W. H. Actual causes of death in the United States. JAMA. 270, 2207–2212, 1993. McGregor, M. J., Le, G., Marion, S. A., & Wiebe, E. Examination for sexual assault: Is the documentation of physical injury associated with the laying of charges? A retrospective cohort study. Canadian Medical Association Journal. 160, 11, 1565–1569, 1999. McGregor, M. J., Lipowska, M., Shah, S., Du Mont, J., & De Siato, C. An exploratory analysis of suspected drugfacilitated sexual assault seen in a hospital emergency department. Women Health. 37, 3, 71–80, 2003. Merchant, R. C., Keshavarz, R., & Low, C. HIV post-exposure prophylaxis provided at an urban paediatric emergency department to female adolescents after sexual assault. Emerg Med J. 21, 4, 449–451, 2004. Michigan Coalition Against Domestic and Sexual Violence. The response to sexual assault: Removing barriers to services and justice. 2004. www.mcadsv.org Miller, B. A., Downs, W. R., Gondoli, D. M., & Keil, A. The role of childhood sexual abuse in the development of alcoholism in women. Violence and Victims. 2, 157–172, 1987.

Sexual Assault

Minshall, L., & Patel, M. Evaluation of documentation practices of sexual assault nurse examiners. California J Emergency Medicine. 2, 3, 28, 2001. Myles, J. E., Hirozawa, A., Katz, M. H., Kimmerling, R., & Bamberger, J. D. Postexposure prophylaxis for HIV after sexual assault. JAMA. 284, 12, 1516–1518, 2000. NCVS. Criminal victimization. U.S. Department of Justice, Office of Justice Programs. 1999–2000. NCVS. Criminal victimization, 2002. U.S. Department of Justice, Office of Justice Programs. August 2003. Negrusz, A., Moore, A., Stockham, C., Poiser, T., Kern, K., Palaparthy, J., Ngoc L. T., Janicak, P., & Levy, N. Elimination of 7-aminoflunitrazepam and flunitrazepam in urine after a single dose of Rohypnol. J Forensic Sciences. 45, 5, 1013–1022, 2000. O’Brien, C. Sexual assault nurse examiner (SANE) program coordinator. J Emerg Nurs. 23, 5, 532–533, 1996. Palmer, C. M., McNulty, A. M., D’Este, C., & Donovan, B. Genital injuries in women reporting sexual assault. Sexual Health. 1, 55–59, 2004. Pitman, R. K. Biological findings in posttraumnatic stress disorder: Implications for DSM-IV classification. In J. R. T. Davidson & E. B. Foa, Eds., Posttraumatic Stress Disorder: DSM-IV and Beyond (pp. 173–189). Washington, DC: American Psychiatric Association Press. 1993. Polusny, M. A., & Follette, V. M. Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Appl Prey Psychol. 4, 3, 143–166, 1997. Putz, M., Thomas, B. K., & Cowles, K. V. Sexual assault victims’ compliance with follow-up care at one sexual assault treatment center. J Emerg Nurs. 22, 6, 560–565, 1996. Rambow, B., Adkinson, C., & Frost, T. H. Female sexual assault: Medical and legal implications. Ann Emerg Med. 21, 6, 727–731, 1992. Rennison, C. Rape and Sexual Assault: Reporting to Police and Medical Attention, 1992–2000. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. NCJ 194530. 2002. Resnick, H. S. Health impact of interpersonal violence.Behav Med. 23, 2, 53–64, 1997. Resnick, H. S., Holmes, M. M., Kilpatrick, D. G., Clum, G., Acierno, R., Best, C. L., & Saunders, B. E. Predictors of post-rape medical care in a national sample of women. Am J Prev Med., 19, 4, 214–219, 2000. Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., & Freedy, J. R. Emotional and physiological responses during a variety of traumatic events. Paper presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Boston, 1992. Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & Best, C. L. Prevalence of civilian trauma and PTSD in a representative national sample of women. J Consult Clin Psychol. 61, 984–991, 1993. Reznic, M. F., Nachman, R., & Hiss, J. Penile lesions: Reinforcing the case against suspects of sexual assault. J Clin Forensic Med. 11, 2, 78–81, 2004. Riggs, N., Houry, D., Long, G., Markovchick, V., & Feldhaus, K. Analysis of 1,076 cases of sexual assault. Annals of Emergency Medicine. 35, 4, 358–362, 2000.

189

Rivara, R. P., Jurkovich, G. J., & Gurney, J. G. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg. 128, 8, 907–912, 1993. Rossman, L., Jones, J. S., Dunnuck, C., Wynn, B. N., & Bermingham, M. Genital trauma associated with forced digital penetration. Am J Emerg Med. 22, 2, 101–104, 2004. Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., & Walsh, W. A prospective examination of post-traumatic stress disorder in rape victims. J Traumatic Stress. 5, 455–475, 1992. Rutledge, R., & Messick, W. J. The association of trauma death and alcohol use in a rural state. J Trauma. 31, 5, 737–742, 1992. Sachs, C. J., & Chu, L. D. Predictors of genitorectal injury in female victims of suspected sexual assault. Acad Emerg Med. 9, 2, 146–151, 2002. Saltzman, L. E. Intimate Partner Violence: Uniform Definitions and Recommended Data Elements, Version 1.0. Atlanta, GA, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 1999. Sandrick, K. M. Medicine & law: Tightening the chain of evidence. Hosp Health Netw., 70, 11, 64, 66, 1996. Schei, B., Muus, K. M., and Moen, M. H. Medical and legal aspects of rape. Referrals to a team for care of rape victims at the regional hospital in Trondheim during the period 1989–1992. Tidsskr Nor Laegeforen. 115, 1, 30–33, 1995. Seneski, P. Multi-disciplinary program helps sexual assault victims. The American College of Physician Executives. 417–418, 1992. Seng, J. S., & Sanubol, M. Johnson County (Iowa) SANE team: The first year as sexual assault nurse examiner: Role transition and role-related stress within a new SANE team. J Emerg Nurs. 30, 2, 126–133, 2004. Sheridan, D. J. The role of the battered woman specialist. J Psychosocial Nursing. 31, 11, 1993. Sievers, V., Murphy, S., & Miller, J. Sexual assault evidence collection more accurate when completed by sexual assault nurse examiners: Colorado’s experience. J Emerg Nurs. 29, 511–514, 2003. Slaughter, L., & Brown, C. R. Cervical findings in rape victims. Am J Obstet Gynecol. 164, 528–529, 1991. Slaughter, L., & Brown, C. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol. 16, 1, 83–86, 1992. Slaughter, L., Brown, C. R., Crowley, S., & Peck, R. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol. 176, 609–616, 1997. Smith, H. G. SART: Special team helps net convictions. Long Beach Press-Telegram. June 5, 1996. Smith, K., Holmseth, J., & Macgregor, M. Sexual assault response team: Overcoming obstacles to program development. J Emerg Nurs. 24, 4, 365–367, 1998. Soderstrom, R. M. Colposcopic documentation: An objective approach to assessing sexual abuse of girls. J Reproductive Medicine. 39, 1, 6–8, 1994. Solola, A., Scott, C., Severs, H., & Howell, J. Rape: Management in a non-institutional setting. Obstetrics & Gynecology. 61, 373–378, 1983.

190

Speck, P. Patient Satisfaction Survey and Memorandum to Nurses. Memphis, TN: Memphis Sexual Assault Resource Center. 1995. Speck, P., & Aiken, M. 20 years of community nursing service. Tennessee Nurse. 58, 2, 5–18, 1995. Stermac, L. E., Du Mont, J. A., & Kalemba, V. Comparison of sexual assaults by strangers and known assailants in an urban population of women. CMAJ. 153, 8, 1089–1094, 1995. Stermac, L. E., & Stirpe, T. S. Efficacy of a two-year-old sexual assault nurse examiner program in a Canadian hospital. J Emerg Nurs. 28, 1, 18–23, 2002. Stobo, J. D., Salmon, M. E., & Cohn, F., Eds. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: National Academy Press. 2002. Sugar, N. F., Fine, D. N., & Eckert, L. O. Physical injury after sexual assault: Findings of a large case series. Am J Obstet Gynecol. 190, 1, 71–76, 2004. Swart, L. A. Rape surveillance through district surgeon offices in Johannesburg, 1996–1998: Findings, evaluation and prevention implications. South African J Psychology. 30, 2–10, 2000. Taylor, W. K. Collecting evidence for sexual assault: The role of the sexual assault nurse examiner (SANE). International J Gynecology and Obstetrics. 78, S91–S94, 2002. Testa, M., Livingston, J. A., & Collins, R. L. The role of women’s alcohol consumption in evaluation of vulnerability to sexual aggression. Exp Clin Psychopharmacol. 8, 2, 185–191, 2000. Testa, M., Vanzile-Tamsen, C., & Livingston, J. A. The role of victim and perpetrator intoxication on sexual assault outcomes. J Stud Alcohol. 65, 3, 320–329, 2004. Thomas, M., & Zachritz, H. Tulsa sexual assault nurse examiners (SANE) program. J Oklahoma State Medical Association. 86, 6, 284–286, 1993. Tobias, G. Rape examinations by GPs. The Practitioner. 234, 1990. Tucker, S., Ledray, L. E., & Stehle-Werner, J. Sexual assault evidence collection. Wisconsin Med J. 89, 407–411, 1990. Turman, D. M. Understanding DNA Evidence: A Guide for Victim Service Providers. Office for Victims of Crime Bulletin. Washington, DC: U.S. Department of Justice, Office of Justice Programs. NCJ 185690. 2001. Voelker, R. Experts hope team approach will improve the quality of rape exams. JAMA. 275, 13, 973–974, 1996. Walch, A. G., & Broadhead, W. E. Prevalence of lifetime sexual victimization among female patients. J Fam Pract. 35, 5, 511–516, 1992. Walker, E. A., & Stenchever, M. A. Sexual victimization and chronic pelvic pain. Obstet Gynecol Clin North Am. 20, 795–807, 1993. Wiebe, E. R., Comay, S. E., McGregor, M., & Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months’ experience in a sexual assault service. CMAJ. 162, 5, 641–645, 2000. Wiley, J., Sugar, N., Fine, D., & Eckert, L. O. Legal outcomes of sexual assault. Am J Obstet Gynecol. 188, 6, 1638–1641, 2003.

Forensic Nursing

World Health Organization. Guidelines for Medico-Legal Care for Victims of Sexual Violence. New York: Author. 2003. Wright, R. J., Wright, R. O., & Farnan, L. Response to child abuse in the pediatric emergency: Need for continued education. Pediatr Emerg Care. 15, 6, 376–382, 1999. Yates, D. W., Hadfield, J. M., & Peters, K. Alcohol consumption of patients attending two accident and emergency departments in north-west England. J Roy Soc Med. 80, 8, 486–489, 1987. Yorker, B. Crofts nurses in Georgia care for survivors of sexual assault. Georgia Nursing. 147, 335–341, 1996. Young, W. W., Bracken, A. C., & Goddard, M. A. Sexual assault: Review of a national model protocol for forensic and medical evaluation. Obstet Gynecol. 80, 5, 878–883, 1992. Yuzpe, A., Smith, A., Percival, R., & Rademaker, A. W. A multicenter clinical investigation employing ethinyl estradiol combined with dl-norgestrel as a post-coital contraceptive agent. Fertility and Sterility. 37, 4, 508–513, 1982.

RECOMMENDED READINGS Abbey, A. Lessons learned and unanswered questions about sexual assault perpetration. J Interpers Violence. 20, 1, 39–42, 2005. Abbey, A., & McAuslan, P. A longitudinal examination of male college students’ perpetration of sexual assault. J Consult Clin Psychol. 72, 5, 747–756, 2004. Ackerman, P. T., Newton, J. E. O., & McPherson, W. B. Prevalence of posttraumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse Negl. 22, 8, 759–774, 1998. ACOG Issues Report on Sexual Assault. Amer Family Phys. 57, 5, 1144–1145, 1998. Adams, J. A. Medical evaluation of suspected child sexual abuse: It’s time for standardized training, referral centers, and routine peer review. Arch Pediatr Adolesc Med. 153, 11, 1121–1122, 1999. Adams, J. A., Harper, K., & Knudson, S. Examination findings in legally confirmed child sexual abuse: It’s normal to be normal. Pediatrics. 94, 3, 310–317, 1994. Adams, J. A., & Wells, R. Normal vs. abnormal genital findings in children: How well do examiners agree? Child Abuse Negl. 17, 5, 663–675, 1993. American College of Emergency Physicians (ACEP). Policy statements: Management of the patient with the complaint of sexual assault. Ann Emerg Med. 25, 728–729, 1995. American College of Obstetricians and Gynecologists (ACOG). Sexual Assault (ACOG Educational Bulletin No. 242). Washington DC: American College of Obstetricians and Gynecologists. 1997. American Medical Association. Strategies for the treatment and prevention of sexual assault. Chicago: American Medical Association. 1995. Ahrens, C. E., Campbell, R., Wasco, S. M., Aponte, G., Grubstein, L., & Davidson, W. S. Sexual assault nurse examiner (SANE) programs: Alternative systems for service

Sexual Assault

delivery for sexual assault victims. J Interpersonal Violence. 15, 9, 921–943, 2000. Aiken, M. M., & Speck, P. M. Sexual assault and multiple trauma: A sexual assault nurse examiner (SANE) challenge. J Emerg Nurs. 2, 466–468, 1995. Ales, B. Community collaboration: The nursing administrator’s role in implementing a child abuse prevention program. J Nurs Admin. 28, 6, 43–48, 1998. Alexander, R. C., & Smith, W. L. Shaken baby syndrome. Infants Young Child. 10, 3, 1–9, 1998. Allen, E. After the examination: Tracking sexual assault cases through the legal system. J Emerg Nurs. 25, 6, 569–571, 1999. American Medical Association, Council on Scientific Affairs. Violence against women: Relevance for medical practitioners. JAMA. 267, 3184–3189, 1992. Anderson, C. Childhood sexually transmitted diseases: One consequence of sexual abuse. Public Health Nurs. 12, 1, 41–46, 1995. ASTM International. Standard guide for sexual assault investigation, examination, and evidence. American Society for Testing and Materials Committee (E-30) on Forensic Sciences. Available at http://www.astm.org. Atabaki, S., & Paradise, J. E. The medical evaluation of the sexually abused child: Lessons from a decade of research. Pediatrics. 104, 1, 178–186, 1999. Bauer, H. M., Mooney, D., & Larkin, H. California’s mandatory reporting of domestic violence injuries: Does the law go too far or not far enough? West J Med. 171, 2, 118–124, 1999. Bays, J., & Chadwick, D. Medical diagnosis of the sexually abused child. Child Abuse Negl. 17, 1, 91–110, 1993. Bays, J., Chewnig, M., & Keltner, L. Changes in hymenal anatomy during examination of prepubertal girls for possible sexual abuse. Adolesc Pedriatr Gynecol. 3, 34–46, 1990. Bays, J., & Lewman, L. Toluidine blue in the detection at autopsy or perineal and anal laceration in victims of sexual abuse. Arch Pathol Lab Med. 116, 620–621, 1992. Beebe, D. K. Emergency management of the adult female rape victim. Amer Family Phys. 43, 6, 2041–2046, 1991a. Beebe, D. K. Initial assessment of the rape victim. J MSMA. 32, 11, 403–406, 1991b. Berenson, A. B. The prepubertal genital exam: What is normal and abnormal. Curr Opin Obstet Gynecol. 6, 6, 526–530, 1994. Berenson, A. B., Chacko, M. R., & Wiemann, C. M. A casecontrol study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol. 182, 4, 820–31, 2000. Berkowitz, C. D. Medical consequences of sexual abuse. Child Abuse Negl. 22, 6, 541–550, 1998. Berliner, L., & Saunders, B. E. Treating fear and anxiety in sexually abused children: Results of a controlled twoyear follow-up study. Child Maltreat. 1, 294–309, 1996. Bernet, W. Practice parameters for the forensic evaluation of children and adolescents who may have been physically or sexually abused. J Am Acad Child Adolesc Psychiatry. 36, 10(Suppl), 37S–56S, 1997. Betchel, K., & Podrazik, M. Evaluation of the adolescent rape victim. Pediatr Clin North Am. 46, 4, 809–823, 1999.

191

Black, C. T. Ano-rectal trauma in children. J Ped Surg. 17, 501–504, 1982. Block, R. What doctors who perform child abuse medical evaluations want the rest of the team to know. J Okla State Med Assoc. 91, 8, 457, 1998. Boney-McCoy, S., & Finkelhor, D. Prior victimization: A risk factor for child sexual abuse and for PTSD-related symptomatology among sexually abused youth. Child Abuse Negl. 19, 12, 1401–1421, 1995. Botash, A. S. Examination for sexual abuse in prepubertal children: An update. Pediatr Ann. 26, 5, 312–320, 1997. Briere, J., & Jordan, C. E. Violence against women: Outcome complexity and implications for assessment and treatment. J Interpers Violence. 19, 11, 1252–1276, 2004. Britton, H., & Hansen, K. Sexual abuse. Clin Obstet Gynecol. 40, 1, 226–240, 1997. Brown, K. Rape and sexual assault: Understanding the offense and the offender. Adv Nurse Pract. 12, 8, 69–70, 2004. Burgess, A. W., & Fawcett, J. The comprehensive sexual assault assessment tool. Nurse Pract. 21, 4, 66, 71–76, 78, 1996. Burgess, A. W., & Holstrum, L. The rape trauma syndrome. Am J Psychiatry. 131, 981–986, 1974. California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims. Sacramento, CA: Office of Criminal Justice Planning. July 1987. Campbell, R. Mental health services for rape survivors: Issues in therapeutic practice. Violence Against Women Online Resources. 1–9, 2001. Campbell, R., Dorey, H., Naegeli, M., Grubstein, L. K., Bennett, K. K., Bonter, F., Smith, P. K., Grzywacz, J., Baker, P. K., & Davidson, S. An empowerment evaluation model for sexual assault programs: Empirical evidence of effectiveness. Am J Community Psychol. 34, 3–4, 251–262, 2004. Cardello, D. Forms, forms, and more forms: Emergency department sexual assault assessment. J Emerg Nurs. 19, 5, 450–451, 1993. Centers for Disease Control and Prevention. Sexual assault and STDs: Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2002. 51, RR-6, 69–74, 2002. Child abuse and forensic pediatric medicine fellowship curriculum statement. American Academy of Pediatrics, Section on Child Abuse and Neglect, and the Forensic Pediatrics Physician Leadership Group, Committee on Fellowship Curriculum. Child Maltreat. 5, 1, 58–62, 2000. Christian, C. W., Lavelle, J. M., & De Jong, A. R. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. 106, 1, 100–104, 2000. Cohen, J. A., & Mannarino, A. P. A treatment model for sexually abused preschoolers. J Interpersonal Violence. 8, 115–131, 1993. Cohen, J. A., & Mannarino, A. P. A treatment outcome study for sexually abused preschool children: Initial findings. J Am Acad Child Adolesc Psychiatry. 3, 1, 42–50, 1996. Coury, D. L. Recognition of child abuse: Notes from the field. Arch Pediatr Adolesc Med. 154, 1, 9–10, 2000. Davidson, D. A. Physical abuse of preschoolers: Identification and intervention through occupational therapy. Am J Occup Ther. 49, 3, 235–243, 1995.

192

Davies, D., Cole, J., & Albertella, G. A model for conducting forensic interviews with child victims of abuse. Child Maltreat. 1, 3, 189–199, 1996. Deblinger, E., Lippmann, U., & Steer, R. A. Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreat. 1, 310–321, 1996. Deblinger, E., Steer, R. A., & Lippmann, J. Maternal factors associated with sexually abused children’s psychosocial adjustment. Child Maltreat. 4, 1, 13–20, 1999a. Deblinger, E., Steer, R. A., & Lippmann, J. Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse Negl. 23, 12, 1371–1378, 1999b. De Jong, A. R. Impact of child sexual abuse medical examinations on dependency and criminal systems. Child Abuse Negl. 22, 6, 645–652, 1998. Deming, J., Mittelman, R., & Wetli, C. Forensic science aspects of fatal sexual assaults on women. J Foren Sci. 28, 3, 572–576, 1983. Dietz, P. E., Hazelwood, R., & Warren, J. The sexually sadistic criminal and his offenses. Bull Am Acad Psych Law. 18, 2, 163–178, 1990. Douglas, J., Burgess, A. W., Burgess, A. G., & Ressler, R. Crime Classification Manual. New York: Lexington Books. 1992. Dubowitz, H. Children’s responses to the evaluation for sexual abuse. Child Abuse Negl. 22, 6, 581–584, 1998. Dubowitz, H., Giardino, A., & Gustavson, E. Child neglect: Guidance for pediatricians. Pediatr in Rev. 21, 4, 111–116, 2000. Dupre, A. R., Hampton, H. L., & Morrison, H. Sexual assault. Obstetrical and Gynecological Survey. 48, 9, 640–648, 1993. Dwyer, B. J. Rape: Psychological medical, and forensic aspects of emergency management. Emergency Medicine Reports. 16, 12, 105–116, 1995. Echeburua, E., de Corral, P., & Sarasua, B. Treatment of acute posttraumatic stress disorder in rape victims: An experimental study. J Anxiety Disord. 10, 185–199, 1996. Emergency Nurses Association (ENA). Position statement. J Emerg Nurs. 24, 5, 38A, 1998. English, D. J. The extent and consequences of child maltreatment. Future Child. 8, 1, 39–53, 1998. Ernst, A. A., Green, E., Ferguson, M. T., Weiss, S. J., & Green, W. M. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. Ann Emerg Med. 36, 5, 432–437, 2000. Ernst, A. A., Houry, D., Weiss, S. J., & Green, W. Domestic violence awareness in a medical school class: Two-year follow-up. South Med J. 93, 8, 772–776, 2000. Ferrell, J. Foley catheter balloon technique for visualizing the hymen in female adolescent sexual abuse victims. J Emerg Nurs. 21, 6, 585–586, 1995. Finkel, M. Technical conduct of the child sexual abuse medical examination. Child Abuse Negl. 22, 6, 555–566, 1998. Flaherty, E. G., Sege, R., & Binns, H. J. Health care providers’ experience reporting child abuse in the primary care setting. Arch Pediatr Adolesc Med. 154, 489–493, 2000.

Forensic Nursing

Foa, E. B., Rothbaum, B. O., & Riggs, D. S. Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol. 59, 5, 715–723, 1991. Friedrich, W. N., Gramsch, P., & Damon, L. Child Sexual Behavior Inventory: Normative and clinical comparisons. Psychol Assess. 4, 303–344, 2002. Fulginiti, T. P., Seibert, E., Firth, V., Quattrone, J., Harner, L., Webb, J., & Vida, P. A SANE experience in a community hospital: Doylestown’s first six months. J Emergency Nursing. 22, 422–425, 1996. Gaffney, D. A., & Ledray, L. Sexual assault examiners and rape crisis advocates: Rising to the challenge together. Sex Assault Rep. 3, 2, 17–32, 1999. Giardino, A. P., Brayden, R. M., & Sugarman, J. M. Residency training in child sexual abuse evaluation. Child Abuse Negl. 22, 4, 331–336, 1998. Giardino, A. P., Christian, C. W., & Giardino, E. R. A Practical Guide to the Evaluation of Child Physical Abuse and Neglect. Thousand Oaks, CA: Sage. 1997. Gostin, L. O., Lazzarini, Z., Alexander, D., Brandt, A. M., Mayer, K. H., & Silverman, D. C. HIV testing, counseling, and prophylaxis after sexual assault. JAMA. 271, 18, 1436–1444, 1994. Green, S. M., Clark, R., Hostetler, M. A., Cohen, M., Carlson, D., Rothrock, S. G. Inadvertent ketamine overdose in children: Clinical manifestations and outcome. Ann Emerg Med. 34, 492–497, 1999. Groth, A. N., & Burgess, A. W. Sexual dysfunction during rape. New England J Medicine, 297, 14, 764–766, 1977. Gully, K. J., Britton, H., & Hansen, K. A new measure for distress during child sexual abuse examinations: The genital examination distress scale. Child Abuse Negl. 23, 1, 61–70, 1999. Hadlich, S. F., & Kohl, P. K. Sexually transmitted diseases in children. Dermatol Clin. 16, 4, 859–861, 1998. Hammerschlag, M. R. Sexually transmitted diseases in sexually abused children: Medical and legal implications. Sex Transm Infect. 74, 3, 167–174, 1998a. Hammerschlag, M. R. The transmissibility of sexually transmitted diseases in sexually abused children. Child Abuse Negl. 22, 6, 623–635, 1998b. Hampton, H. L. Care of the woman who has been raped. N Engl J Med. 332, 4, 234–237, 1995. Hanson, R. F., Resnick, H. S., & Saunders, B. E. Factors related to the reporting of childhood sexual assault. Child Abuse Negl. 23, 6, 559–569, 1999. Hazelwood, R., & Burgess, A., Eds. Practical Aspects of Rape Investigation: A Multidisciplinary Approach. New York: Elsevier. 1987. Heger, A. H. Evaluation of sexual assault in the emergency department. Top Emerg Med. 21, 2, 46–57, 1999. Heger, A. H., & Emans, S. J. Evaluation of the Sexually Abused Child: Textbook and Atlas. New York: Oxford University Press. 1992. Hochmeister, M. N., Whelan, M., & Borer, U. V. Effects of toluidine blue and destaining reagents used in sexual assault examinations on the ability to obtain DNA profiles from postcoital vaginal swabs. J Forensic Sci. 42, 2, 316–319, 1997.

Sexual Assault

Holmes, W. S. Sexual abuse of boys: Definition, prevalence, correlates, sequelae and management. JAMA. 280, 21, 1855–1862, 1998. International Association of Forensic Nurses. Scope and Standards of Forensic Nursing Practice. Pitman, NJ: International Association of Forensic Nurses. Available at: http://www.forensicnurse.org. International Association of Forensic Nurses. Sexual Assault Nurse Examiner Education Guidelines. Pitman, NJ: International Association of Forensic Nurses. 1997. Available at: http://www.forensicnurse.org. International Association of Forensic Nurses. Forensic nursing on trial: Virginia judge’s decision in sexual assault case places forensic nursing in the forefront of law and medicine [Press release]. Pitman, NJ: International Association of Forensic Nurses. April 25, 2001. Available at: http://www.forensicnurse.org. Jackman, T. When rape is in question, so are nurses’ answers. Washington Post. April 2, 2001, B1, B4. Jaeger, B. Sexual assault nurse examiners. J Emerg Nurs. 24, 5, 440–441, 1998. Jansen, K. Using ketamine to induce the near-death experience: Mechanism of action and therapeutic potential. Yearbook for Ethnomedicine and the Study of Consciousness. 55–81, 1996. Jaudes, P. K., & Martone, M. Interdisciplinary evaluations of alleged sexual abuse cases. Pediatrics. 89, 6, 1164–1168, 1992. Jenny, C. Pediatrics and child sexual abuse: Where we’ve been and where we’re going. Pediatr Ann. 26, 5, 284–286, 1997. Jezierski, M. Sexual assault nurse examiner: A role with lifetime impact. J Emerg Nurs. 18, 2, 177–179, 1992. Jones, J. S., Dunnuck, C., Rossman, L., Wynn, B. N., & Genco, M. Adolescent foley catheter technique for visualizing hymenal injuries in adolescent sexual assault. Acad Emerg Med. 10, 9, 1001–1004, 2003. Jones, J. S., Rossman, L., Wynn, B. N., Dunnuck, C., & Schwartz, N. Comparative analysis of adult vs. adolescent sexual assault: Epidemiology and patterns of anogenital injury. Acad Emerg Med. 10, 8, 872–877, 2003. Kaplan, D. W., Feinstein, R. A., & Fisher, M. Care of the adolescent sexual assault victim. Pediatrics. 107, b, 1476–1479, 2001. Kaplan, S. J., Pelcovitz, D., & Labruna, V. Child and adolescent abuse and neglect research: A review of the past 10 years. J Am Acad Child Adolesc Psychiatr. 38, 10, 1214–1222, 1999. Karch, S. B. Ketamine: The hot new drug of abuse. Forensic Drug Abuse Advisor. 9, 6, 1–2, 1997. Kelley, S. J., & Yorker, B. C. The role of non-physician health care providers in the physical assessment and diagnosis of suspected child maltreatment: Results of a national survey. Child Maltreat. 2, 4, 331–340, 1997. Kellogg, N. D. The pediatrician’s role in child abuse: Position statement of the Texas pediatrician society, a chapter of the American Academy of Pediatrics, Committee on Child Abuse. Tex Med. 95, 2, 69–71, 1999. Kenney, M. J. A sexual assault record. J Emerg Nurs. 20, 6, 560–561, 1994.

193

Kerns, D. L. Establishing a medical research agenda for child sexual abuse: Historical perspective and executive summary. Child Abuse Negl. 22, 6, 453–465, 1998a. Kerns, D. L. Triage and referrals for child sexual abuse medical examinations: Which children are likely to have positive medical findings? Child Abuse Negl. 22, 6, 515–518, 1998. Kiffe, B. Perceptions: Responsibility Attributions of Rape Victims [Thesis]. Augsburg College, Minneapolis, MN. 1996. King, N. J., Tonge, B. J, & Mullen, P. Treating sexually abused children with post-traumatic stress symptoms: A randomized clinical trial. J Am Acad Child Adolesc Psychiatry. 39, 11, 1347–1355, 2000. Kivlahan, C., Kruse R., & Furnell, D. Sexual assault examinations in children: The role of a statewide network of health care providers. American J Diseases in Childhood. 146, 11, 1365–1370, 1992. Koss, M. P., Koss, P. G., Woodruff, W. J. Deleterious effects of criminal victimization on women's health and medical utilization. Arch Intern Med. 151, 2, 342–347, 1991. Krugman, R. D. Child abuse and neglect: A worldwide problem. Child Abuse Negl. 19(3) 1995. Lamb, M. E., Sternberg, K. J., & Esplin, P. W. Conducting investigative interviews of alleged sexual abuse victims. Child Abuse Negl. 22, 8, 813–823, 1998. Lancon, J. A., Haines, D. E., & Parent, A. D. Anatomy of the shaken baby syndrome. Anat Rec. 253, 1, 13–18, 1998. Lang, K. Sexual Assault Nurse Examiner Resource Guide for Michigan Communities. Okemos, MI: Michigan Coalition against Domestic and Sexual Violence. 1999. Lauber, A., & Souma, M. Use of toluidine blue for documentation of traumatic intercourse. Obstet & Gynecol. 60, 5, 644–648, 1982. LeBeau, M., Andollo, W., & Hearn, W. L. Recommendations for toxicological investigations of drug-facilitated sexual assaults. J Forensic Sci. 44, 1, 227–230, 1999. Ledray, L. E. Counseling rape victims: The nursing challenge. Perspectives in Psychiatric Care. 26, 2, 21–27, 1990. Ledray, L. E. The sexual assault examination: Overview and lessons learned in one program. J Emer Nurs. 18, 3, 223–230, 1992. Ledray, L. E. Sexual assault nurse clinician: An emerging area of nursing expertise. AWHONN’s Clinical Issues in Perinatal and Women’s Health Nursing. 4, 2, 180–190, 1993. Ledray, L. E. Sexual assault: Clinical issues: Sexual assault evidentiary exam and treatment protocol. J Emerg Nurs. 21, 21, 355–359, 1995. Ledray, L. E., & Arndt, S. Examining the sexual assault victim: A new model for nursing care. J Psychosocial Nursing Mental Health Services. 32, 7–12, 1994. Levitt, C. Further technical considerations regarding conducting and documenting the child sexual abuse medical examination. Child Abuse Negl. 22, 6, 567–568, 1998. Lynch, L., & Faust, J. Reduction of distress in children undergoing sexual abuse medical examination. J Pediatr. 132, 2, 296–299, 1998. McCann, J. Use of the colposcope in childhood sexual abuse examinations. Pediatr Clin North Am. 37, 4, 863–880, 1990.

194

McCann, J. The appearance of acute, healing, and healed anogenital trauma. Child Abuse Negl. 22, 6, 605–615, 1998. McCauley, J., Guzinski, G., Welch, R., Gorman, R., & Osmers, F. Toluidine blue in the corroboration of rape in the adult victim. Am J Emerg Med. 5, 2, 105–108, 1987. Merritt, D. F. Evaluation of vaginal bleeding in the preadolescent child. Semin Pediatr Surg. 7, 1, 35–42, 1998. Miller, T. R., Cohen, M. A., & Wiersema, B. Victim Costs and Consequences: A New Look. Washington, DC: National Institute of Justice. 1996. Mok, J. Y. When is HIV an issue after child sexual abuse? Arch Dis Child. 75, 1, 85–87, 1996. Monk, M. Interviewing suspected victims of child maltreatment in the emergency department. J Emerg Nurs. 24, 1, 31–34, 1998. Muram, D. Child sexual abuse: Genital tract findings in prepubertal girls: Comparison of colposcopic and unaided examinations. Am J Obstet Gynecol. 160, 333–335, 1989. Muram, D. A., Aiken, M. M., & Strong, C. Children’s refusal of gynecologic examinations for suspected sexual abuse. J Clin Ethics. 8, 2, 158–164, 1997. Muram, D., Arheart, K. L., & Jennings, S. G. Diagnostic accuracy of colposcopic photographs in child sexual abuse evaluations. J Pediatr Adolesc Gynecol. 12, 2, 588–561, 1999. Muram, D., & Laufer, M. R. Limitations of the medical evaluation for child sexual abuse. J Reprod Med. 44, 12, 993–999, 1999. National Center for Injury Protection and Control Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention. 1999. National Center for Victims of Crime and Crime Victims Research and Treatment Center. Rape in America: A Report to the Nation. Arlington, VA: National Center for Victims of Crime. 1992. National Center for Victims of Crime. Issues: Payment for Forensic Exams. Prepared for the 2001 Sexual Assault Response Team (SART) Conference. 2001. Available at: http://www.ncvc.org/policy/issues/forensicexams/. National Center for Victims of Crime. Payment of sexual assault forensic exams. Victim Policy Pipeline. 7, 1, 2001. National Institute of Justice. The Extent and Costs of Crime Victimization: A New Look. Washington, DC: U.S. Department of Justice, Office of Justice Programs. 1996. Nieves-Khouw, F. C. Recognizing victims of physical and sexual abuse. Crit Care Nurs Clin North Am. 9, 2, 141–148, 1997. Norvell, M. K., Benrubi, G. I., & Thompson, R. J. Investigation of microtrauma after sexual intercourse. J Reprod Med. 29, 269–271, 1984. Osatlin, A., & Short, L. M. Intimate partner violence and sexual assault: A guide to training materials and programs for health care providers. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 1998. Osborn, M., & Bryan, S. Patient care guidelines: Evidentiary examination in sexual assault. J Emerg Nurs. 15, 3, 284–290, 1989.

Forensic Nursing

Paolucci, E. O., Genuis, M. L., & Violato, C. A meta-analysis of the published research on the effects of child sexual abuse. J Psychol. 135, 1, 17–36, 2001. Paradise, J. E., Finkel, M. A., & Beiser, A. S. Assessment of girls’ genital findings and the likelihood of sexual abuse. Arch Pediatr Adolesc Med. 151, 9, 883–891, 1997. Pasqualone, G. A. Forensic RNs as photographers: Documentation in the ED. J Psychoso Nurs. 34, 10, 47–53, 1996. Patterson, J. J. Honing our clinical awareness of sexual abuse. J Am Osteopath Assoc. 89, 5, 617, 1989. Persaud, D. I., Squires, J. E., & Rubin-Remer, D. Use of foley catheter to examine estrogenized hymens for evidence of sexual abuse. J Pediatr Adolesc Gynecol. 10, 2, 83–85, 1997. Petrak, J. A., Skinner, C. J., Claydon, E.J. The prevalence of sexual assault in a genitourinary medicine clinic: Service implications. Genitourin Med. 71, 2, 98–102. 1995. Pharris, M. D., & Ledray, L. E. Consent and confidentiality in the care of the sexually assaulted adolescent. J Emerg Nurs. 23, 3, 279–281, 1997. Poliak, L., & Chang, E. Nancy Cabelus: Bringing forth justice: Sexual assault nurse examiners. Am J Nurs. 104, 9, 94–95, 2004. Pressel, D. M. Evaluation of physical abuse in children. Am Fam Physician. 61, 10, 3057–3064, 2000. Rand M. Changes 1996–7 with Trends. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, Criminal Victimization 1997. Publication No. NCJ 173385. 1998. Resnick, H., Acierno, R., & Holmes, M. Prevention of post-rape psychopathology: Preliminary findings of a controlled acute rape treatment study. J Anxiety Disord. 13, 4, 359–370, 1999. Ricci, L. Medical forensic photography of the sexually abused child. Child Abuse Neglect. 12, 305–310, 1998. Robinson, A. J., Watkeys, J., & Ridgway, G. L. Sexually transmitted organisms in sexually abused children. Arch Dis Child. 79, 4, 356–358, 1998. Rodgers, G. D. Sequelae of sexual assault. Primary Care Update for Ob/Gyns. 4, 4, 143–146, 1997. Rogers D. Physical aspects of alleged sexual assaults. Med Sci Law. 36, 2, 117–122, 1996. Rothbaum, B. O. A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims. Bull Menninger Clin. 61, 3, 317–334, 1997. Roye, C. F., & Coonan, P. R. Emergency! Adolescent rape. Am J Nurs. 97, 4, 45, 1997. Santucci, K. A., Nelson, D. G., & McQuillen, K. K. Wood’s lamp utility in the identification of semen. Pediatrics. 104, 6, 1342–1344, 1999. Satin, A. J., Hemsell, D. L., Stone, I. C. Jr, Theriot, S. & Wendel G.D. Jr. Sexual assault in pregnancy. Obstetrics and Gynecology. 77, 710–714, 1991. Saunders, B. E., Kilpatrick, D. G., & Hanson, R. F. Prevalence, case characteristics, and long-term psychological correlates of child rape among women: A national survey. Child Maltreat. 4, 3, 187–200, 1999.

Sexual Assault

Savino, J. O., & Turvey, B. E., Eds. Rape Investigation Handbook. New York: Elsevier. 2005. Schiff, A. F. Examination and treatment of the male rape victim. Southern Medical J. 73, 1498–1502, 1980. Schwartz, R. H., & Weaver, A. B. Rohypnol the date rate drug. Clin Ped. 36, 321, 1998. Scott, D. L., Schelbe, D. T., & White, L. J. An important question in the evaluation of sexual assault victims. Acad Emerg Med. 4, 4, 329–330, 1997. Shapiro, R. How to interpret results of a child sexual abuse examination: What conditions may be mistaken for sexual abuse? In D. A. DePanifilis, Ed., Handbook for Child Protection Practice. Thousand Oaks, CA: Sage. 2000a. Shapiro, R. The medical evaluation for possible child sexual abuse: When it is needed, who should provide it, what will be done and how to prepare the child? In D. A. DePanfilis, Ed., Handbook for Child Protective Practice. Thousand Oaks, CA: Sage. 2000b. Siegel, R. M., Schubert, C. J., & Myers, P. A. The prevalence of sexually transmitted diseases in children and adolescents evaluated for sexual abuse in Cincinnati: Rationale for limited STD testing in prepubertal girls. Pediatrics. 96, 6, 1090–1094, 1995. Simmons, M., & Cupp, M. J. Use and abuse of flunitrazepam. Ann Pharmacotherapy. 32, 117–119, 1998. Skinner, C. J., & Forster, G. The coexistence of physical and sexual assault. Am J Obstet Gynecol. May, 172, 5, 1644, 1995. Sloan, L. Sexual assault nurse examiners: The new challenges. Sex Assault Report. 2, 6, 81–96, 1999. Smith, K., Holmseth, J., Macgregor, M., & Letourneau, M. Sexual assault response team: Overcoming obstacles to program development. J Emerg Nurs. 24, 4, 365–367, 1998. Smock, W. S., Nichols, G. R., & Fuller, P. M. Development and implementation of the first clinical forensic medicine training program. J Forensic Sci. 38, 4, 835–839, 1993. Socolar, R. R. Physician knowledge of child sexual abuse. Child Abuse Negl. 20, 8, 783–790, 1996. Socolar, R. R., Raines, B., & Chen-Mok, M. Intervention to improve physician documentation and knowledge of child sexual abuse: A randomized, controlled trial. Pediatrics. 101, 5, 817–824, 1998. Spohn, C., & Horney, J. Rape law reform: A grassroots revolution and its impact. New York: Plenum. 1992. Springs, F. E., & Friedrich, W. N. Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clin Proc. 67, 527–532, 1992. Starling, S. P., Sirotnak, A. P., & Jenny, C. Child abuse and forensic pediatric medicine fellowship curriculum statement. Child Maltreat. 5, 1, 58–62, 2000. Stephenson, T. & Bialas, Y. Estimation of the age of bruising. Arch Dis Child. 74, 1, 53–55, 1996. Teixeira, R. G. Hymenal colposcopic examination in sexual offenses. Am J Forensic Med Pathol. 2, 209–214, 1981. Tintinalli, J. E., & Hoelzer, M. Clinical findings and legal resolution in sexual assault. Annals of Emerg Med. 14, 5, 447–453, 1985. Tjaden, P., & Thoennes, N. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women.

195

Washington, DC: U.S. Department of Justice, Office of Justice Programs. NCJ 183781. 2000. Tucker, S., Ledray, L. E., & Werner, J. S. Sexual assault evidence collection. Wis Med J. 89, 7, 407–411, 1990. Ullman, S. Do social reactions to sexual assault victims vary by support provider? Violence and Victims. 11, 143–156, 1996. Underhill, R. A., & Dewhurst, J. The doctor cannot always tell: Medical examination of the “intact” hymen. The Lancet. 1, 375–376, 1978. U.S. Department of Health and Human Services, Administration on Children, Youth, and Families, Children’s Bureau. Child Maltreatment 2000: Reports from the States to the National Child Abuse and Neglect Data System (NCANDS). Washington, DC: U.S. Department of Health and Human Services. 2002. U.S. Department of Health and Human Services, Administration on Children, Youth, and Families, Children’s Bureau. Child Abuse and Neglect State Statutes Series Compendium of Laws: Reporting Laws. Washington, DC: National Clearinghouse on Child Abuse and Neglect Information. 2002. U.S. Department of Health and Human Services, Administration on Children, Youth, and Families, Children’s Bureau. Statutes at a Glance 2002: Mandatory Reporters of Child Abuse and Neglect. Child Abuse and Neglect State Statutes Series. Washington, DC: National Clearinghouse on Child Abuse and Neglect Information. 2002. U.S. Department of Justice. Criminal victimization 2000: Changes 1999–2000, with Trends 1993–2000, Bulletin. Washington, DC: U.S. Department of Justice, Office of Justice Programs. NCJ 187007. 2001. U.S. Department of Justice. Sexual Assault Nurse Examiner (SANE) Programs: Improving the Community Response to Sexual Assault Victims. Washington, DC: U.S. Department of Justice, Office of Justice Programs. NCJ 186366. 2001. U.S. Department of Justice. Sourcebook of Criminal Justice Statistics, 2000. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. NCJ 190251. 2001. U.S. Department of Justice. Criminal victimization, 1996: Changes 1995–96 with trends 1993–96. Washington, DC: Bureau of Justice Statistics. 1997. U.S. Department of Justice, Office on Violence Against Women. A national protocol for sexual assault medical forensic examinations: Adults/adolescents. Washington, DC: Office of Violence Against Women, 2004. Uttley, L., & Petraitis, C. Rape survivors and emergency contraception: Substandard care at hospital emergency rooms. Prochoice Ideas. 3–4, 2000. Veronen, L. J., & Kilpatrick, D. G. Self-reported fears of rape victims: A preliminary investigation. Behav Modif. 4, 383–396, 1980. Voelker, R. Experts hope team approach will improve the quality of rape exams. JAMA. 275, 973–974, 1996. Waibel-Duncan, M. K., & Sanger, M. Understanding and reacting to the anogenital exam: Implications for patient preparation. Child Abuse Negl. 23, 3, 281–286, 1999.

196

Walter, H. Genital pathology: Its impact on the interpretation of signs of genital trauma. J Clin Forensic Med. 5, 2, 85–89, 1998. Woodling, B. A., & Heger A. The use of the colposcope in the diagnosis of sexual abuse in the pediatric age group. Child Abuse Neglect. 10, 111–114, 1986. Woodtli, M. A., & Breslin, E. Violence-related content in the nursing curriculum: A national study. J Nurs Ed. 35, 8, 367–377, 1996. Xenarios, S., Reichert, K., & Giordano, L. Implementing a multidisciplinary sexual assault forensic examiner program in

Forensic Nursing

an urban teaching hospital setting. Paper presented at the National Sexual Violence Prevention Conference: Coming Together to End Sexual Assault, Dallas, TX, 2000. Young, W. W., Bracken, A. C., & Goddard, M. A. Sexual assault: Review of a national model protocol for forensic and medical evaluation. Obstet Gynecol. 80, 5, 878–883, 1992. Zorza, J. Effects of childhood sexual abuse on male survivors. Sexual Assault Report. 3, 1, 1–13, 1999a. Zorza, J. Male rape: Men raping men. Sexual Assault Report. 2, 4, 1–2, 1999b.

7 Interpersonal Violence CONTENTS 7.1 7.2 7.3

The Scope of the Problem..................................................................................................................................... 197 Domestic Violence in Urban Versus Rural Settings ............................................................................................. 199 The Health Care System’s Response to Interpersonal Violence .......................................................................... 200 7.3.1 Ways to Increase Understanding of Violence Against Women as a Critical Public Health Problem ......... 204 7.4 Health Care Providers’ Role in IPV Cases ........................................................................................................... 208 7.4.2 Training of Health Care Providers in IPV Issues ..................................................................................... 208 7.5 The Mental and Physical Impacts of IPV............................................................................................................. 209 7.5.1 Women’s Childhood Abuse Linked to Later Poor Health........................................................................ 210 7.6 Domestic Violence Cases: The ED Portal ............................................................................................................ 210 7.6.1 The Health Care Provider’s Response to Domestic Violence Presenting in the ER ............................... 212 7.6.2 Screening for IPV by Health Care Providers ........................................................................................... 213 7.6.3 Mandatory Reporting of IPV by Health Care Providers.......................................................................... 214 7.6.4 The Physician’s Role in IPV Cases .......................................................................................................... 215 7.6.5 Domestic Violence Recognized, Not Always Investigated by Medical Students .................................... 216 7.6.6 Physicians Less Likely to Screen, But More Likely to Intervene in Domestic Violence ....................... 217 7.6.7 Women’s Shame Stalls Abuse Disclosure to Health Care Providers ....................................................... 217 7.6.8 Health Care Providers Need More Training to Spot and Intervene in Cases of Domestic Violence ......... 218 7.6.9 Nurses Can Help Violence Victims Find a Solution ................................................................................ 218 7.7 The Scope of Partner Violence.............................................................................................................................. 219 7.7.1 The Three Faces of Domestic Violence .................................................................................................... 220 7.7.2 Intimate Partner Violence and Homicide .................................................................................................. 220 7.7.3 The Disturbing Trend of “Femicide” ........................................................................................................ 221 7.8 A National Consensus on Domestic Violence ...................................................................................................... 222 7.8.1 Health Effects of Intimate Partner Violence ............................................................................................. 223 7.8.2 Identifying and Responding to Abuse Can Make a Difference ............................................................... 224 7.8.3 Conducting the Intimate Partner Violence Inquiry ................................................................................... 225 7.8.3.1 Conducting the Health and Safety Assessment ......................................................................... 225 7.8.3.2 Reporting Cases of Intimate Partner Violence .......................................................................... 226 7.8.3.3 Documentation ........................................................................................................................... 226 7.8.3.4 Continuity of Care for the Patient ............................................................................................. 227 7.8.3.5 Challenges for the Health Care Provider When Screening Patients for Intimate Partner Violence..................................................................................................... 227 7.9 The Family Justice Center Concept ...................................................................................................................... 228 7.10 The Future.............................................................................................................................................................. 235 References ....................................................................................................................................................................... 235 Recommended Readings ................................................................................................................................................. 237

7.1 THE SCOPE OF THE PROBLEM Violence that hits home has many names: domestic violence, spousal abuse, interpersonal violence (IPV), and family violence. No matter the nomenclature, IPV is a serious problem with sweeping implications for men, women, and children throughout the human life span.

Although statistics are disputed frequently, the CDC (2000) estimates that up to one quarter of the U.S. population is affected by some type of IPV. The determination of incidence and prevalence is made more difficult by the fact that IPV can be acute or chronic, subtle or extreme. According to Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence, 197

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published by The National Academies of Sciences (2000), violence is generally divided into four categories: 1. 2. 3. 4.

Physical violence Sexual violence The threat of physical or sexual violence Psychological or emotional abuse

Victims of IPV include both women and men, in heterosexual and same-sex relationships, but women abused by current or former intimate male partners are the most frequently abused and sustain the highest rates of injury. Lifetime incidence rates vary widely, depending on the type of violence assessed, but they tend to be in the 15 percent to 30 percent range. In contrast, intimate partner violence accounts for 3 percent of violence against men, and rates of violence by women against men are generally lower. In the mid-1980s, U.S. surgeon generals began drawing attention to domestic violence and the act of victimization by an intimate partner. Men are the perpetrators in 90 percent of all reported domestic assaults, and women are 10 times as likely as men to be injured in episodes of domestic abuse. Among female murder victims in this country, about one third are slain by their husbands or boyfriends each year, whereas only 4 percent of all male victims are killed by their wives or girlfriends (Bachman, 1994; Zawitz, 1994). In 2004, advocates and activists celebrated the 10th anniversary of the landmark Violence Against Women Act (VAWA), the ground-breaking legislation and policy that addressed violence, abuse, and assault against women. A report by Congressional Research Service (CRS) on the VAWA and its impacts stated that the law helped define the problem and enabled the health care, law enforcement, and legal communities to start putting their collective arms around this growing problem. It also stated that for the first time, IPV was being viewed as a serious crime, rather than a private family issue or personal problem. However, the report indicates that many victims, even with the passage of a decade, fail to report abuse because they still believe it is a private matter, or for fear of retaliation from the abuser. The CRS found the following: •

•

•

From 1998 to 2000, states passed more than 650 laws to combat violence, sexual assault, and stalking. From 1993 to 2001, the NCVS found that violence against women was cut in half from 1.1 million nonfatal violent crimes in 1993 to 588,490 female victims in 2001. The percentage of women who experienced violence from an intimate partner and reported it increased from 48 percent in 1993 to 59 percent

in 1998. The report attributes this to stronger arrest policies (Family Violence Prevention Fund, 2004). McFarlane et al. (2005) sought to describe the characteristics and consequences of sexual assault within intimate relationships specific to racial or ethnic group, compare the findings to a similar group of physically assaulted women, and measure the risk of reassault after victim contact with justice and health services. The researchers conducted a personal interview survey of 148 African American, Hispanic, and White English- and Spanishspeaking abused women seeking a protection order. Extent of sexual assault, prevalence of rape-related STDs and pregnancy, symptoms of PTSD and depression, and risk of reassault after treatment were measured. Sixty-eight percent of the physically abused women reported sexual assault; 15 percent of the women attributed one or more STDs to sexual assault, and 20 percent of the women experienced a rape-related pregnancy. Sexually assaulted women reported significantly more PTSD symptoms compared with nonsexually assaulted women. One significant difference occurred between ethnic groups and PTSD scores. Regardless of sexual assault or no assault, Hispanic women reported significantly higher mean PTSD scores compared with African American women and White women. The risk of sexual reassault was decreased by 59 percent and 70 percent for women who contacted the police or applied for a protection order, respectively, after the first sexual assault. Receiving medical care decreased the woman’s risk of further sexual assault by 32 percent. Stark, Flitcraft, and Frazier (1997) and McLeer and Anwar (1989) report that the first prevalence studies of domestic violence in the medical setting, which were conducted in hospital EDs, demonstrated that domestic violence accounted for 22 percent to 35 percent of women seen in the ED. Studies of patients in internal medicine, obstetrics, and family practice clinics have been conducted to estimate the prevalence of domestic violence seen in the primary-care setting. According to these studies, 12 percent to 28 percent of outpatients in these settings have reported current involvement in violent relationships. In the studies of lifetime experience with violence, between 28 percent and 54 percent of patients reported having lived with a violent partner at some previous time (Elliott & Johnson, 1995; Hamberger, Saunders, & Hovey, 1992; Gin et al., 1991; Rath, Jarratt, & Leonardson, 1989). These rates are much higher than those of the national incidence and prevalence studies (Elliott & Johnson, 1995; Koss, Koss, & Woodruff, 1991; Saunders, Hamberger, & Hovey, 1993), which documented that battered women are more frequent users of health care services than women who are not battered.

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7.2 DOMESTIC VIOLENCE IN URBAN VERSUS RURAL SETTINGS To date, most of what is known about the prevalence of domestic violence in rural settings comes from federal incidence and prevalence statistics that are based on the definition of rural as a nonmetropolitan area comprising sparsely populated areas that include cities with populations of less than 50,000. According to these statistics, women have the same risk of experiencing domestic violence regardless of where they live, although women living in central cities are more vulnerable to all types of violent crime perpetrated by strangers. Marilou Johnson, MD, and Barbara A. Elliott, PhD, compared the domestic violence experiences of female patients in rural outpatient clinics with what the authors learned from their earlier research about the prevalence and characteristics of domestic violence among women patients in the larger community setting. The study’s sample was comprised of women seen in one family practice clinic (FPC) in a city of 85,000 people, as well as in two FPCs in rural communities of less than 10,000. Of the 219 women seen in all three clinics, 200 were eligible by study parameters, and 127 participated. The women seen in the rural clinics were significantly older than those served by the clinic in the largest community, and they had significantly more and older children. The rural women were also less likely to be employed and were more likely to have either dropped out of high school or not to have pursued education beyond high school. Elliott and Johnson (1995) found that 46 percent of the 127 women interviewed reported some experience with violence; 21 percent reported ongoing abuse by their current partner, and 28 percent reported violence in past relationships. Twenty-two women (17 percent) reported violence only in their current relationship, 31 (24 percent) only in past relationships, and 4 (3 percent) reported violence in both past and ongoing relationships. There was only one difference between women battered in the larger community compared with those battered in rural settings: Involvement in an ongoing abusive relationship was significantly more common among rural women than among women in the city (25 percent vs. 12 percent). The researchers found that the women reported various abusive experiences. Some form of physical abuse was reported by 37 women (29 percent); sexual abuse was reported by 19 women (15 percent), and threats involving weapons by 118 women (4 percent). Every woman who reported physical violence also reported emotional and social abuse. Twentythree percent of the women with a history of abuse—10 percent of the entire sample—reported experiencing physical abuse and threats with weapons, in addition to emotional and social abuse. Twenty-one percent of those with any history of abuse had experienced emotional and social abuse only. For the group with a past history of abuse, 11

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percent reported emotional and social abuse only, whereas 31 percent of those currently in an abusive relationship reported emotional and social abuse only. When asked to detail the frequency of abusive episodes, 13 currently abused women commented. Six of these women reported that abusive events tended to occur at least once a week, and for eight of the women, physical violence occurred at least every three months. Five women reported a single episode of physical violence. The researchers say that correlations among the types of abuse indicate that women commonly experience more than one type of domestic violence; moderate battery and severe battery often occur together. Threatened or actual use of weapons does not often occur with severe battery or sexual violence, although it usually accompanies emotional and social abuse. Sexual abuse also accompanies moderate battery. Of the women reporting moderate battery and sexual violence, 62 percent also reported severe battery. Interestingly, sexual abuse was not correlated with social abuse. Elliott and Johnson looked at the purpose of their participants’ medical visits on the day of the interview. Of those who had never been battered, 38 percent were in the clinic for preventive care, including physical and prenatal examinations. Only half as many of the women currently being abused were being seen for preventive visits; 81 percent of them had come in for episodic care with specific complaints, including neck stiffness, twisted ankles, refills of antidepressant medication, migraine headaches, injured arms, sinus infection, hip pain, and depression. The primary reasons for the clinic visit given by women who had been abused in the past included depression, leg injury, sinus infection, amenorrhea, and pelvic pain, although more of them came for preventive care than currently abused women did. In their interviews of study participants, Elliott and Johnson heard vivid stories about the severity and frequency of physical violence, and the women’s fears that they were going to be killed. They reported that several women said they had been beaten during pregnancy, and one reported that she lost a pregnancy as a result of a beating. Another woman reported an episode in which she was forcibly held in a door frame for 30 minutes. Still another woman described having her head banged on the sidewalk, and another told of being shoved down the steps and dragged through the hallway by her hair. Many women reported acts of physical violence that occurred at least once a week, and fear of an upcoming violent episode was a constant theme. One woman reported that if more than a week went by between abusive episodes, she “huddled around the corner waiting for what would come next.” At least two of the women reported being beaten or choked as they slept. Expressions of violence also included weapons. The husband of one woman cleaned his guns during arguments. Other men reportedly threw kitchen knives at their partners or actually held a knife blade to their throats.

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Some women reported that their partners threatened to kill them and then take their own lives. One man wrote suicide letters to his children during an initial separation from his wife, and another held a loaded gun to his head in front of his daughter and her friend. Despite being divorced from her husband for four years, another woman stated that her biggest fear was that “I’ll be walking around one day and he will simply kill me.” When asked how she coped with such a frightening threat to her life, still another woman explained that she never really thought of the danger of it, but that she had to “keep a sort of even tone” to her thoughts so that she would not lose her mind. Equally striking was the woman whose husband held a loaded gun to her head every day. She denied being abused, saying, “My face isn’t covered with bruises like those women in the posters.” The women also reported sexual abuse that intensified the sexual humiliation and degradation they experienced. When asked if she had been forced to have sex, one woman explained that she had not been physically forced but had been asked to do “terrible things which I went along with because I didn’t know any better.” For some women, sexual humiliation became public. Over the course of their marriage, one man frequently made sexually explicit and degrading remarks about his wife in public, usually in front of their friends. Several women reported being forced to have intercourse when their partners were drunk, and another reported that if she wanted something, she had to earn it by having sex with her husband; toward the end of this pair’s relationship, however, he would simply throw her on the floor and rape her. Elliott and Johnson say, “An insidious form of abuse that accompanies physical violence is the gradual social and psychological isolation created by the batterer.” Regardless of location, most of the women participating in this study reported being isolated from their friends and family. Rural women live with an additional dimension of separation: By living in a rural area, the batterer ensures geographic isolation. One woman who lived 13 miles out of town reported that no car was available to her because either she did not have her partner’s permission to use it or he intentionally disabled the car. Several rural women also reported that they had been regularly left to care for their small children without access to vehicles until medical emergencies convinced their partners to leave a car at home “for the sake of the kids.” Elliott and Johnson say their study underscores the need for health care providers to have a high index of suspicion regarding potential cases of domestic violence. They write, “Women in battering relationships present to family practice clinics primarily for episodic care. Therefore, if physicians ask about violence only during extended visits, such as those for preventive care, these women will be missed.” They add, “The prevalence rates and the characteristics of violence experienced by women documented

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in our study indicate that physicians should routinely screen their patients for battery, educate all patients about domestic violence, assess the level of danger, review safety plans with their patients, and refer those who are living with its consequences. This screening process will help identify women in abusive relationships.”

7.3 THE HEALTH CARE SYSTEM’S RESPONSE TO INTERPERSONAL VIOLENCE In Improving the Health and Mental Health Care Systems’ Responses to Violence Against Women, Toolkit to End Violence Against Women (2001), the Violence Against Women Office of the U.S. Justice Department outlines what health care and mental health care systems can do to make a difference in the lives of victims of violence. The white paper states: Millions of women are victims of sexual assault, dating or domestic violence, or stalking at some point in their lives, and the traumatic effects of this violence have a tremendous impact on survivors’ physical and mental health. Too many victims never discuss incidents of violence with anyone or approach the health and mental health care, criminal justice, or other system for assistance. However, most women come to health care settings for regular exams, for treatment of specific problems both caused by and independent of the abuse, and for the care of their children and other family members. Health care providers may be the first and only professionals who see a battered woman or sexual assault victim. This makes the health and mental health care systems crucial points for early intervention and prevention for women who have survived or are experiencing violence.

The health effects of violence against women are extensive. In addition to possible acute injuries sustained during sexual assault or domestic violence, physical, sexual, and psychological abuse are linked to numerous adverse chronic health conditions, including arthritis, chronic neck or back pain, frequent migraines or other types of headaches, visual problems, STIs, chronic pelvic pain, increased gynecological symptoms, peptic ulcers, and functional or irritable bowel disease (Coker et al., 1997). Violence against women is also directly related to adverse mental health effects. Sexual assault trauma and domestic violence are often life-altering experiences resulting in numerous emotional and behavioral responses. Kilpatrick, Edmunds, and Seymour (1992) found that sexual assault victims are more likely than other crime victims to attempt suicide, while Housekamp and Foy (1991) discovered that more than one third of sexual assault victims and battered women experience symptoms of depression. Kilpatrick et al. reported that 46 percent of domestic violence victims have symptoms of anxiety

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disorder, and victims of both sexual assault and domestic violence experience symptoms consistent with PTSD. Persistent sexual victimization occurring early in childhood can lead to a range of disorders that can arise anytime after the traumatic event and last indefinitely until appropriate treatment is received (Golding, 1999; Housekamp & Foy, 1991; Kilpatrick et al., 1985) Resulting behaviors, such as drug abuse or prostitution, might be deemed criminal and could result in the person being punished. Numerous studies nationwide consistently show prevalence rates of sexual abuse histories at 22 percent to 54 percent among women receiving case management mental health services and 50 percent to 70 percent among women in inpatient psychiatric facilities (Briere et al., 1997; Craine, Henson, Collier, & MacLean, 1998; Nibert, Cooper, & Crossmaker, 1989). Many health care and mental health care providers still do not view sexual assault, dating and domestic violence, and stalking as public health issues and lack the knowledge, skills, and incentives to intervene appropriately. For example, only 9 percent to 11 percent of the primary care physicians in California routinely screen patients for domestic violence during new patient visits, periodic checkups, and prenatal care (Rodriguez, Bauer, McLaughlin, & Grumbach, 1999). Friedman et al. (1992) found that patients and physicians at both a private and a public hospital favored the practice of doctors inquiring about physical and sexual abuse, yet 89 percent of the physicians never made such inquiries. Health problems of the magnitude described earlier require a broad public health approach with comprehensive prevention strategies and commitment to ongoing evaluation. When such strategies are effective, they can prevent health problems (primary prevention) or identify a problem in its earliest stages (secondary prevention). In this way, harm to individuals is reduced, and the long-term adverse impact on a patient’s health (including mental health) is minimized. For example, early detection programs for breast, cervical, and prostate cancer can identify and treat these problems before the disease reaches advanced stages. When primary or secondary prevention strategies are not implemented or are ineffective, tertiary prevention—a strategy that limits the impact of an injury or disability once it has become serious—is needed. Until recently, the health care system has addressed sexual assault and domestic violence predominantly through tertiary prevention strategies. Sexual assault programs handle crisis calls from victims and survivors, and shelters provide temporary housing for women and children seeking refuge from abuse. The criminal justice system reacts to violent incidents with sanctions for perpetrators. Similarly, health and mental health care professionals treat the presenting problem (suturing lacerations, setting broken bones, and prescribing antidepressants) usually without exploring the underlying problem.

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In one study of 476 consecutive women seen by an FPC in the midwest, 394 (82.7 percent) agreed to be surveyed. Of these patients, 22.7 percent had been physically assaulted by their partners within the last year, and 38.8 percent of them endured lifetime physical abuse. However, only six women said they had ever been asked about the occurrence of domestic violence by their physician (Hamberger et al., 1992). If violence against women is to be stopped, screening and intervention in the health care setting must be supplemented with broad-based public education efforts that inform and address deep-seated attitudes and give people tools for action in the communities in which they live. Despite some gains, far too many Americans continue to hold attitudes that can be construed as excusing the sexual abuser or batterer for his behavior or blaming victims for precipitating the violence. These attitudes contribute to pervasive social norms that tolerate and permit abuse. Almost every clinical health and mental health care provider treats victims of sexual assault and domestic violence, although most are unaware that their patients have formerly or recently been abused. Historically, health care providers have viewed violence against women as a social or legal issue or even as a private family problem, outside their purview and inappropriate to address in a clinical setting. Only recently has the situation begun to change. At the clinical care level, health care and mental health care institutions and systems are encouraged to implement changes designed to create comprehensive standards of care for victims of violence against women. The standards should include the following: •

•

Access to health and mental health care. Basic, quality, affordable services should be available to all women regardless of age, geographic or language barriers, sexual orientation, or ability to pay. Routine screening by trained health care providers. All adult and teenage women should be screened routinely for intimate partner violence following a screening protocol that ensures patient privacy, safety, and confidentiality. Resources must be invested to develop and test sexual assault screening instruments and to train providers across all health specialties on the use of these tools and appropriate referrals. Screening for violence based on observed injuries alone does not account for the toll of psychological abuse or unseen injuries and eliminates many opportunities for early intervention and prevention. By asking simple and direct questions regarding abuse and sexual assault, trained health care providers engage in vital prevention and early intervention by sending a message to women that violence against

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•

•

them is a health issue, that they are not alone, and that health care providers know and care about sexual assault and domestic violence. Documenting violence against women. Acute incidents of sexual assault and domestic violence should be documented accurately, nonjudgmentally, and in detail in the medical record. Documentation of sexual and domestic violence improves both continuity and quality of care by allowing the provider to understand the impact of violence on current and future health problems or injuries. Proper documentation also facilitates reimbursement and referral to additional services, but confidentiality must be maintained throughout the process. Detailed documentation in the medical record also serves as compelling evidence when a victim seeks legal recourse. On a system level, a large number of documented abuse and sexual assault incidents justifies the allocation of additional dedicated services for victims in the medical and mental health care setting. However, more study is needed to determine the best approach to documenting an adult patient’s history of child sexual abuse and adult nonacute sexual assault, given how prejudicial such information can be if used improperly. Intervention and referral. Once abuse is identified and documented, an appropriate response should ensue. This response can vary depending on the internal and community-based resources of the health care facility and the desires of each survivor. Multidisciplinary protocols that incorporate the roles and responsibilities of all staff who interact with victims of violence against women can ensure that victims receive the support and services they need. Although some health care facilities have in-house advocates to provide victims with resources and support, such as safety assessment and planning or counseling, others might need to partner with local sexual assault and domestic violence victim advocates and refer appropriately. Regardless of the setting, health care providers must develop culturally competent, creative, and effective strategies to assist victims. Development of a coordinated and collaborative system of referral, follow-up care, and onsite services is critical in improving the safety, recovery process, and health status of victims. Clinical interventions should be tailored to respond to the range of racial, ethnic, and socioeconomic characteristics of patients, as well as address the particular needs of women with disabilities and women of all ages and sexual orientations. Literacy levels

should also be considered when developing screening questions and patient information. The clear lesson of the past two decades of efforts to improve health care’s response to violence against women is that the system must be engaged at every level to ensure that meaningful public health efforts and effective sustainable clinical interventions occur. Early efforts focused on creating protocols to guide the care of victims of domestic violence. Although the JCAHO mandated that health care settings develop protocols on identifying and responding to sexual assault and domestic violence, protocols unaccompanied by other strategies did not improve screening and intervention. Efforts shifted to supplementing protocols with training for individual providers on the dynamics of and responses to sexual assault and dating and domestic violence. Training, along with increasingly strengthened JCAHO requirements, successfully raised individual provider awareness of and sensitivity to the issue. Single providers, however, have often lacked the organizational support necessary to continue to respond to victims. Those striving to improve the health care system’s response to domestic violence began by training multidisciplinary teams consisting of nurses, physicians, advocates, social workers, and administrators. By organizing and training a range of stakeholders in an institution, awareness and response was more widespread, consistent, and long-lasting. These teams met with more success in screening and assisting victims through their policy change efforts, creating a multidisciplinary response, and instituting new clinical tools, but the demands of the increasingly complicated health care system, as well as staff turnover, still make routine screening and response difficult. To address the particular needs of sexual assault victims who sought medical assistance soon after an assault, a multidisciplinary response was developed, coordinating crisis intervention services and professional forensic evidence collection when the victim wanted to report the assault to law enforcement. For these victims, a new area of medical specialization has evolved, the SANE or SAFE. SANEs are trained medical professionals who have advanced education and clinical preparation in the forensic examination of sexual assault victims and who partner with local victim advocates to provide support during the forensic exam and coordinate follow-up services. When a victim wants to report an assault to law enforcement, existing relationships between the SANE, victim advocate, and police department facilitate a victim-centered response. Some communities have established SARTs to coordinate these efforts. Protocols and individual and team training are all crucial, but they must be joined by broader reforms of institutions and policies that affect health care delivery and inform public health strategies, according to

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the Violence Against Women Office of the U.S. Justice Department. This agency suggests the following steps: •

•

•

•

Confidentiality of health records. An essential corollary to documentation of abuse in medical records is the confidentiality of these medical records. Women who have been sexually assaulted, abused, or stalked share with many other health care consumers concerns about inappropriate access to and use of medical record information by insurance companies, employers, and law enforcement agencies. In addition, victims of domestic violence have the added concern of potential perpetrator access. Few laws exist to prevent spousal access to medical records. Removing barriers to forensic sexual assault exams and related treatment. One problem is the practice of conditioning medical or forensic services to requirements that the victim report to law enforcement agencies or participate in court proceedings. Such practices compromise sexual assault survivors’ access to the emergency health care services they might need and could place them at further risk. Mandatory reporting to law enforcement by health care providers. With increased recognition that violence against women is a public health issue, some jurisdictions have instituted policies that require a health care provider to report domestic violence, and sometimes sexual assault, to law enforcement authorities. Growing evidence suggests that mandatory reporting might not improve a patient’s health and safety and might discourage some victims from seeking medical care. More research is needed on the unintended consequences of these policies and how they affect victims’ safety and health before they are established in any more institutions. Creating reimbursement mechanisms, coding, and other incentives to provide care for victims of violence against women. Currently, no specific current procedural terminology (CPT) codes for domestic violence screening or intervention exist. However, diagnostic codes capture additional information such as the nature of the abuse and perpetrators. Although clinicians can use the general preventive medicine codes to bill for domestic violence screening performed in the context of a comprehensive preventive medicine assessment and preventive medicine counseling codes for domestic violence safety assessment and referral processes, there are many compelling reasons to develop

•

codes specific to domestic violence screening and intervention. First, a specific billing code would provide a direct financial incentive to reward clinicians for the time spent screening and intervening in cases of domestic violence. Second, specific codes would facilitate the process of evaluating how frequently screening is being performed. Third, specific codes for screening and intervention would make it easier for population-based delivery systems to provide feedback to medical groups and individual clinicians on how well they are performing compared with national standards and peers. For example, a review of specific coding might reveal how many women per 1,000 were screened in cases of domestic violence or what percentage of screened women received an intervention. Measured performance can be tied to both financial and nonfinancial incentives to drive more rapid improvement. Finally, specific codes for domestic violence screening and intervention would indicate to the health care community that these services are as valuable as other services for which specific codes already exist. Appropriate use of existing diagnostic codes can be an important source of data about domestic violence and can be used by health plans and other population-based delivery systems to track incidence, associated costs, utilization patterns, and effectiveness of interventions. This type of administrative data can also be used by researchers to answer many important questions about how to design programs that will improve the health care system’s response to victims of domestic violence. As documentation and coding for domestic abuse and dating violence is improved, issues concerning confidentiality of the information must be rigorously addressed. Financial and nonfinancial incentives that promote evaluation and intervention services for victims of domestic violence at all levels of the health care system must be developed and implemented. Purchasers, health plans, and other insurers might be motivated to “buy” or implement comprehensive domestic violence programs if they are presented with the business case for such programs. In addition to being paid for delivering domestic violence services, clinicians should be encouraged to improve performance. Institutions must prioritize the creation of comprehensive packaged services for victims of domestic violence. Models that require multifaceted responses including medical care, counseling, assessment, case management, and

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•

mental health counseling and referrals should be used to create systems that encourage response to dating and domestic violence. Creating appropriate measures of health outcomes. Much of contemporary health care delivery is shaped by health-outcome measures. Many health issues have obvious means to measure successful treatment or intervention. Effective outcome measures must be established to guide care delivery to victims of violence against women.

7.3.1 WAYS TO INCREASE UNDERSTANDING OF VIOLENCE AGAINST WOMEN AS A CRITICAL PUBLIC HEALTH PROBLEM 1. Conduct public health campaigns about violence against women at the same level as other large-scale public education campaigns. • Communicate the serious consequences that violence against women has on all aspects of health and mental health so that the public no longer minimizes the problems or views them as solely private or criminal justice issues. • Encourage public health leaders, including the Secretary of Health and Human Services, the Surgeon General, and state and local public health figures, to continue to identify sexual assault, dating and domestic violence, and stalking as serious public health issues and call for comprehensive responses. • Emulate campaign strategies that addressed other health issues that were considered largely private or social in nature. Consider those that resulted in greater willingness of individual providers to screen and intervene and in patient willingness to turn to health care providers for assistance. • Integrate messages about violence against women into other health education campaigns. Look for opportunities to include information about sexual assault, dating and domestic violence, and stalking into education that targets behavior often associated with the aftereffects of sexual assault, including but not limited to teen pregnancy, unsafe sex, STDs, and alcohol and other drug use. • Target funds to develop campaigns that respond to a wide range of factors, such as race, ethnicity, socioeconomic level, age, disability, and literacy level. Research shows that linguistically and culturally appropriate campaigns are significantly more effective.

2. Educate all health care providers and public health professionals on violence against women. • Because violence affects so many aspects of physical and mental health and women enter the health care system through various types of providers, institutions, government health programs, and managed care systems, engage every type of provider, institution, and system in education efforts. 3. Develop professional school curricula that address violence against women. • Fully integrate information on violence against women into standard curriculums at all health care and public health professional schools. • Include information on the dynamics, epidemiology, and direct and indirect effects of sexual assault, dating and domestic violence, and stalking, as well as clinical skills such as screening, documentation, and response. • Although specialized sections on specific issues are necessary, integrate information about violence against women throughout course work whenever appropriate. • Offer specific modules on improving the cultural and linguistic competence of practices for all levels of providers. Integrate examples of culturally and linguistically competent practices and cases that deal with various patient populations in training that addresses violence against women. 4. As part of continuing education for providers, offer specific modules on violence against women, and recognize achievements in the field. • Ensure that training related to violence against women is a component providers receive to become or remain licensed to practice. • Involve sexual assault and domestic violence advocates and survivors in the development and implementation of continuing education on violence against women. • Include questions related to both the dynamics and effects of violence against women and appropriate clinical responses on licensure and certification examinations. • Provide training and promote effective clinical guidelines and standards of care that reflect routine screening, documentation, appropriate assessment, intervention, and referral. • Create association-wide member awareness campaigns around sexual assault, dating and domestic violence, and stalking.

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• Target primary care, reproductive health, emergency, mental health, pediatric, and other specialty organizations that see women regularly. • Integrate violence against women into association member recognition programs. • Increase the availability of technical assistance and training for health care providers who want to become SANEs and professionals who want to improve multidisciplinary responses to sexual assault. • Follow recommendations of the IAFN, which requires the completion of 40 contact hours approved through a recognized continuing education body or offered through a college or university. • Participate in continuing education and ongoing training to maintain proficiency with new technologies and research findings. 5. Engage all types of providers and institutions. • Primary-care settings offer opportunities for early intervention, and even primary prevention, by identifying sexual or domestic abuse as a health issue in its early stages or before it begins. • Mental health professionals are key points of contact who see victims for problems of anxiety, depression, PTSD, suicide attempts, and other psychological problems highly associated with violence against women. • Obstetricians, gynecologists, women’s health nurse practitioners, and nurse midwives are important players because sexual assault survivors often experience anxiety about pelvic examinations and because data suggest that the onset of abuse is often associated with pregnancy. • Pediatricians and pediatric nurse practitioners can identify victims of domestic violence and offer the resources and support necessary to stop the abuse before it takes its toll on the mothers and children they are treating. • SANEs see victims of sexual assault as well as victims of domestic violence. • Dentists and oral surgeons might see women for treatment of oral injuries, such as fractured jaws, and for regular check-ups, during which abuse can be identified by routine screening even in the absence of acute injuries. They might also have patients who have specific fears or reactions concerning their dental care because of a history of sexual assault.

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• Substance abuse counselors see many women who are victims of sexual assault and domestic violence and who use alcohol or other drugs as a way of coping with the trauma. Research has shown victimization to be a risk factor for substance abuse. • Specialists such as orthopedic and plastic surgeons, radiologists, and home health care nurses and attendants each have an important stake in identifying and responding to abuse among their patients. Pain management centers could see many women who suffer from chronic pain due to abuse. • Inpatient health care settings, such as psychiatric facilities and nursing homes, are urged to work with community sexual assault and domestic violence programs to provide training and develop policies and services that respond to the needs of patients who enter with a history of assault or who are assaulted while in the institution. • All types of health care organizations must be engaged, including community health centers; home health and visiting nurses agencies; managed care organizations; private hospitals and practices; alternative healing centers; Indian Health Services; military health entities; Women, Infants, and Children (WIC) and Medicaid programs; and state and federal public health departments and agencies. • Businesses and other health care purchasers can create the institutional support and incentives that promote training and an improved response by their providers and insurers. 6. Expand SANE programs to all communities throughout the country. • Increase the capacity of existing SANEs to address the complex health and forensic needs of victims, including the domestic violence victims experiencing forced sex by their partners. • Provide increased funding and technical assistance to support program development in underserved areas, in collaboration with local and state sexual assault programs and coalitions. 7. Design mental health services to respond to the needs of victims and survivors of sexual assault, dating and domestic violence, and stalking. • Designate funds to provide quality mental health services for treating the traumatic sequelae of abuse for victims of sexual assault, dating and domestic violence, and

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stalking, including adult survivors of child sexual abuse living in rural areas. • Develop collaborative models for addressing the social and advocacy needs and the psychological needs of survivors of sexual assault, dating and domestic violence, and stalking. • Designate program and training resources to improve quality of care in public mental health systems to address trauma and its sequelae across the life span. • Provide training for community mental health centers to address sexual assault and domestic violence for women diagnosed with serious mental illness and for women who are experiencing other mental health sequelae of sexual assault, dating and domestic violence, and stalking. • Provide resources for sexual assault and domestic violence victim advocacy programs to provide onsite services and develop contractual arrangements with mental health providers and agencies to address the mental health sequelae of violence against women. Foster greater collaboration between mental health professionals, sexual assault victim advocates, alcohol and other drug abuse treatment providers, and criminal justice personnel. • Develop curriculums and training materials for mental health providers (e.g., psychiatrists, psychologists, social workers, and marital and family therapists) to address issues faced by women who are being or have been sexually, emotionally, or physically abused. 8. Develop and support the widespread use of provider and institution clinical tools that respond to sexual assault and domestic violence. • Develop patient charts, new-patient intake forms, and other clinical tools that support appropriate screening, documentation, and response to victims of sexual assault, dating and domestic violence, and stalking. • Include prompts for providing sexual assault victims with information on available forensic medical examinations in sexual assault protocols, and ensure access to appropriate equipment and staff training on its proper use. • Post local, state, and national hotline telephone numbers for victims of sexual assault and domestic violence in all examination rooms and patient bathrooms. • Develop practitioner reference cards that address sexual assault, dating and domestic

violence, and stalking. Include sexual assault and domestic violence information on Web sites designed for health care provider and patient reference. • Equip examination rooms with body maps available for documenting injuries. Equip EDs, acute care centers, and other sites that see injuries caused by domestic violence with instant cameras. • Scrutinize all standard tools to ensure they include information about violence against women. 9. Use funding, licensing, and credentialing mechanisms to ensure that health care institutions have relevant response protocols for violence against women. • Require grantees to have policies, protocols, training requirements, incentives, and other relevant responses to violence against women. • Create and strengthen guidelines regarding sexual assault, dating and domestic violence, and stalking, including guidelines for screening. 10. Fully protect the confidentiality of victims’ health records. • Implement safeguards, under federal, tribal, and state laws, to ensure that health records of victims of sexual assault, dating and domestic violence, and stalking are not accessed inappropriately by insurance companies, employers, or spouses and partners. Protect privileged medical and mental health information from discovery and other legal actions during the course of a criminal proceeding. • Build into current policy necessary protections for patients who might be endangered under routine directory information, next of kin, and other practices in health care institutions. Allow victims to restrict access to their patient information. • Allow victims to request that bills and explanations of benefits be sent to alternate addresses. • Remove information regarding abuse from the records of victims and their children before releasing them to spouses or partners. Notify victims before any required release of abuse-related information to facilitate their safety planning. • Allow minors who lawfully receive care on their own to restrict access to records regarding abuse.

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11. Reduce or eliminate cost and reporting requirements for victims needing forensic medical exams or related treatment after a sexual assault. • Earmark state funds to cover costs of forensic medical exams for victims of sexual assault without seeking reimbursement from the victim or from any public or private health insurance under which the victim might otherwise be covered. • Adopt current federal guidelines governing victim compensation agencies, which permit reimbursement of examination costs to hospitals and other medical facilities regardless of whether the assault is reported to law enforcement authorities. • Include care for acute symptoms and prophylaxis for pregnancy, STD transmission, and treatment for the hepatitis B virus when appropriate as part of emergency medical care associated with an assault. 12. Amend mandatory reporting laws regarding adult victims of violence to ensure that the laws increase victim safety and health status and do not deter women from seeking care. • Require patient consent—except in cases of gunshot wounds or life-threatening injuries—before health care providers report violent incidents to law enforcement agencies. • Increase awareness of the problems that arise from mandatory reporting for women who are undocumented and the subsequent immigration problems. 13. Create reimbursement mechanisms, coding, and other incentives to provide quality care to victims of violence against women. • Educate clinicians and medical coders on the importance of including the existing International Classification of Diseases, Ninth Revision (ICD-9) codes for adult abuse and e-codes, particularly those that describe the relationship of the perpetrator to the patient, either as primary or secondary diagnostic codes. Failure to add an adult abuse code to the medical record means that information about the root cause of an injury or illness is not captured and therefore might not be appropriately addressed in follow-up encounters. • Promote the use of existing ICD-9 codes, including the use of e-codes to define the relationship of the perpetrator to the patient, through medical coder professional organizations, national health care provider organizations, state medical boards, and the use of federal and state government advisories.

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• Develop and implement at least two CPT codes specific to domestic violence screening and intervention. • Develop the business case for domestic violence services in the health care setting. • Develop model incentive programs that reward purchasers, plans, other insurers, and clinicians for domestic violence screening and intervention. 14. Provide incentives for individual health care providers to address the violence against women issues of their patients. • Provide feedback on performance compared to peers and national standards. • Tie monetary rewards to attaining defined performance goals with respect to screening and intervention. • Provide public recognition for high performers (e.g., newspaper articles, plaques presented at medical society meetings). • Design and implement formal mechanisms to give providers feedback from patients who value these services. • Support the clinician’s role in responding to sexual assault and domestic violence by developing in-house services for victims of sexual assault and domestic violence or by contracting with community organizations to provide onsite or on-call access to their specialized services. 15. Prioritize the creation of comprehensive packaged services for victims of sexual assault, dating and domestic violence, and stalking. • Develop models for delivering multifaceted responses, including medical care, counseling, assessment, case management, and mental health counseling and referrals. • Examine Medicaid program models that could reimburse health plans for the provision of patient education and case management, safety assessment, and referrals in violence against women cases in low-income communities. 16. Establish appropriate health outcome measures related to improved health care response to violence against women. • Convene a task force of leading advocates, survivors, health care providers, researchers, and federal representatives to create health plan employer data and information set measures for sexual assault and domestic violence. • Explore the full range of possible outcome measures, including decreased health care use, fewer secondary health effects related

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to violence, and victim perception of improved physical and mental health status and safety. • Develop and provide funds to implement a research agenda that establishes the medical evidence for effective intervention and improved health outcomes and increased safety. 17. Increase funding to improve the health and mental health care systems’ response to violence against women. • Explore the creation of new funding streams that can be dedicated to improving the health and mental health care systems’ responses to violence against women. • Earmark specific funding within state and local health department budgets for improving health care responses to sexual assault and domestic violence. • Provide funds for health care provider training, institutional reform, patient education, and public health campaigns to reflect the prevalence of violence and its impact on health costs.

7.4 HEALTH CARE PROVIDERS’ ROLE IN IPV CASES 7.4.1 ATTITUDES OF HEALTH CARE PROVIDERS TOWARD IPV Moore, Zaccaro, and Parsons (1998) compared the education, attitudes, and practices related to domestic violence of nurses from three types of practice sites: public health, hospital, and physician’s offices. The sample consisted of 275 nurses. The researchers found some differences in beliefs among the nurses, but even greater differences were identified in their behaviors. Only 54 percent of the nurses reported receiving education about domestic violence in formal or continuing education programs. Public health nurses were the most likely to have such education. In the total sample, 31 percent of nurses reported personal accounts of abuse or abuse toward family members. The researchers concluded that many nurses in this study lacked education about domestic violence, and that the provision of education about abuse and domestic violence is an important first step toward a change in nursing practice. High rates of family violence and low rates of detection, reporting, and therapeutic intervention by health professionals are well documented. Tilden et al. (1994) attempted to determine what factors influence clinicians’ decision making about identifying abuse and intervening with victims. Survey data about clinicians’ experiences with and attitudes toward family violence were gathered

Forensic Nursing

through mailed questionnaires to a random sample of practicing clinicians in six disciplines. Data showed similarities within and wide differences among three groups of participants: dentists and dental hygienists, nurses and physicians, and psychologists and social workers. Overall, a third of the study participants reported having received no educational content on child, spouse, or elder abuse in their professional training programs. Those with education on the topic more commonly suspected abuse in their patients than those without; among all participants, spouse abuse was suspected more often than child abuse, whereas elder abuse was suspected infrequently. Significant numbers of participants did not view themselves as responsible for dealing with problems of family violence. Respondents indicated low confidence in and low compliance with mandatory reporting laws. The researchers concluded that there is a need for educators to expand curricula on family violence, and for legislators to reexamine mandatory reporting laws.

7.4.2 TRAINING OF HEALTH CARE PROVIDERS IN IPV ISSUES In 1998, the American Academy of Pediatrics (AAP) issued guidelines for pediatricians to screen for domestic violence and for residency programs to include domestic violence education. Bair-Merritt et al. (2004) attempted to assess chief residents’ attitudes and training regarding domestic violence screening. A 53-question survey was mailed to the chief residents of 194 nonmilitary U.S. pediatric residency programs, and 68 percent of surveys were returned. Although 93 percent of chief residents felt that pediatricians should screen for domestic violence, only 21 percent screen every patient. Just 24 percent agreed or strongly agreed that they felt experienced in handling domestic violence cases. Although 60 percent of respondents said that they received 11 or more hours of residency training in how to handle child abuse, the majority (80 percent) received four hours or less of training. Seventyone percent agreed or strongly agreed that pediatricians do not screen secondary to lack of training. The researchers conclude that although many pediatric chief residents believe that domestic violence is a significant pediatric health problem, screening practices are variable. They add, “Most chief residents feel that their training was not sufficient to make them comfortable screening for DV. Chief residents demonstrated openness to incorporating DV training into their programs, indicating a positive environment for DV curricula.” Several studies have demonstrated that textbooks for physicians and nurses are lacking in content addressing IPV issues. Parsons and Moore (1997) evaluated major texts in obstetrics and gynecology, primary care, and nursing for their content in the area of family violence. The study included 48 medical texts and 19 nursing texts pub-

Interpersonal Violence

lished between 1990 and 1996. Key words and phrases were identified and indexes were searched; the minimum requirements for content on domestic violence included 12 issues identified as important. If the text contained any information on an issue, it received one point. A domestic violence content score was calculated, and a maximum score of 12 was possible. Textbooks were evaluated for content related to domestic violence as well as rape, child sexual abuse, abuse in pregnancy, and elder abuse. Thirtyseven percent of physician texts and 63 percent of nursing texts included some content on domestic violence. On the researchers’ domestic violence content scale, 16 percent of medicine texts and 10 percent of nursing texts scored 9 to 12. The researchers concluded, “The availability of information on family violence is limited in both medical and nursing texts.” Appropriate educational preparation about violence prevention, assessment, and treatment provides critical knowledge and skills that enable nurses to provide competent care to violence survivors. Woodtli and Breslin (2002) conducted a national survey that examined changes in the extent, placement, and faculty responsible for violencerelated content in baccalaureate nursing curricula since their original 1995 survey was conducted. This national study used a 31-item mailed questionnaire that requested demographic information; data related to course content, clinical experiences, curriculum and faculty development; curriculum evaluation; and recommendations. Usable questionnaires were returned from 395 (61 percent) of 648 programs surveyed. Findings indicated that content related to women, children, and suicide and self-destructive behavior was taught primarily in two to four hours; 46 percent of schools presented sexual and elder abuse content in one hour or in readings only; and related clinical experiences were primarily coincidental. The majority of schools (63 percent) reported no violence-related faculty development activities during the past four years despite previous indication of need. More than two thirds of programs (68 percent) did not systematically evaluate violence content, and three quarters had not developed violence-focused student competencies. Although small gains were found in hours of presentation in some content, the researchers discovered that little has changed in the nursing curriculum overall. The authors of the study call into question the relevance of nursing education to preparing students and faculty to address the social and health problems of increasing violence and abuse. In Intimate Partner Violence: A Death Sentence for Women, Joellen W. Hawkins (2002), RNC, PhD, FAAN, says that nurse practitioners can play a valuable role in assisting victims of violence. “Making screening for violence an integral part of every patient visit will ensure that women know that our practice sites are safe places to talk about their concerns when they are ready and able to do so,” she writes. “We should explore conflict in relation-

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ships, how women handle crises in their lives, and relate health concerns to abuse. We need to raise the index of suspicion when women present with recurrent health problems or injuries and children exhibit signs of witnessing violence.” She points to Campbell, Sharps, Campbell, and Lopez (2002), who said, “Each entry point into a health care setting has the potential for initiating an intervention or referral to prevent or reduce further violence against women.”

7.5 THE MENTAL AND PHYSICAL IMPACTS OF IPV Numerous studies have documented IPV’s impact on the health and well-being of adults and children. The effects of child abuse and neglect range from the negligible to severe injury and even death. Physical abuse can consist of single or multiple bruises, burns, fractures, abdominal injuries, and head injuries. The consequences of sexual abuse of a child depend on the age of the child, the duration of the abuse, the relationship of the child to the abuser, and the amount of coercion used to sustain the abusive relationship. Emotional neglect can lead to significant developmental, emotional, and behavioral problems later in life. In addition to the immediate effects of the mistreatment of children, there are well-documented, longterm consequences that can occur in adulthood, including increased risk for somatic, psychosomatic, and psychiatric problems. The effects of witnessing IPV in the home are not yet fully understood, but there is some evidence to suggest that there are emotional and developmental effects. As with other forms of IPV, the most severe medical consequence is death, and intimate partners constitute the largest single category of perpetrators in the homicide of women, according to the CDC (2000). Nonfatal intimate partner violence is also associated with a variety of physical, psychological, and psychosomatic complaints, including headache, chronic pain, gastrointestinal and gynecological symptoms, STDs, unintended pregnancies, urinary tract infections, depression and anxiety, suicide, substance abuse, and PTSD. Tjaden and Thoennes (2000) found that of the 4.8 million cases of intimate partner physical and sexual abuse of women estimated annually, approximately 2 million resulted in injury to the victim, and of these, 552,192 resulted in medical treatment. Wisner (1999) states that intimate partner violence appears to be a significant predictor of hospitalizations, general clinic use, mental health service use, and out-of-plan referrals. Kimerling and Calhoun (1994) found that 72 percent of sexual assault victims in the study sample sought medical attention, and 19 percent sought psychiatric treatment. The full economic cost of IPV has not been determined, but what is known suggests that it is quite high. Rudman

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(2002) suggests that a hospitalized patient who has been identified as a victim of IPV will cost a median of $873 more than a patient with the same condition who has not been identified as a victim. Direct medical costs of care for victims of IPV are estimated at $1.8 billion annually (Miller et al., 1993). Between 850,000 and 1.5 million women are assaulted by their partners each year. The 2001 crime statistics showed that physical abuse (including sexual assaults) occurred in 172 women every 60 minutes. These same statistics showed that an episode of rape occurred every two minutes, and that a woman was abused by her male partner every nine seconds. In 1998, estimates of violence against women included 876,340 rapes, sexual assaults, robberies, aggravated assaults, and simple assaults. The 1998 statistics also showed 160,000 violent crimes against men. However, domestic violence occurred most frequently against women, and 95 percent of all victims of intimate partner abuse were female. Researchers suggested that violence results in more injuries than rape, motor vehicle crashes, and muggings combined. In 1999, 1,218 women were murdered by intimate partners. In a study from 1993 to 1999, 45 percent of female murder victims between the ages of 20 and 24 were killed by intimate partners. Another study showed that 50 percent of all female murder victims were killed by male partners. An estimated 4,084 cases of same-sex domestic violence were reported in 2000 with an almost 50 percent division between women and men. The National Domestic Violence Hotline reported that from February 1996 to December 2001, 700,000 calls were placed for assistance. Reports also indicated that an estimated 324,000 pregnant women are victims of intimate partner violence each year. Of 10,000 women visiting EDs each year, at least 40 percent had some form of domestic violence in her past or present history. In 2000, approximately 1,200 children died of maltreatment, a rate of 1.71 per 100,000 children. Child protective services agencies reported that 3 million referrals concerning 5 million children were made to their offices in the year 2000. Of these referrals, approximately 879,000 children (32 percent) were cases of maltreatment of children from birth to 3 years of age. This age group had the highest rate of 13.9 per 1,000 children and included neglect, physical abuse, sexual abuse, and psychological maltreatment. A comparison of abuse and neglect of children over time showed a decline in cases since 1993, but a possible increase in 2000. In 1993, 15.3 children per 1,000 were victims. In 1999, the number dropped to 11.8 victims per 1,000, but increased to 12.2 per 1,000 in 2000. Authorities believe that the recent increase is due, at least in part, to “more timely completion of investigations, a cleared backlog of investigations awaiting dispositions or a reduced rate in 1999 . . . due to census population estimates.” There also has been an increased awareness and ease of reporting. Neglect, a subset of violence, is much harder to define

Forensic Nursing

or detect. It has not been spotlighted for the public’s information as much as physical violence. It has been defined as the failure of a caretaker to provide the goods or services that are necessary to avoid physical harm, mental anguish, or mental illness. Patients, often children and the elderly, who are dehydrated, malnourished, have poor hygiene, are inappropriately dressed, or have received medications improperly should be further assessed for neglect.

7.5.1 WOMEN’S CHILDHOOD ABUSE LINKED LATER POOR HEALTH

TO

Women who were physically abused as children are more likely to report having poor health than those who did not experience such abuse, according to a 2003 study in the American Journal of Preventive Medicine. The study, based on survey results from 3,527 women in the state of Washington, also suggests that that women who were physically abused or who witnessed violence between their parents are also more likely to experience intimate partner violence and emotional abuse as adults. Women who were sexually abused but did not suffer other physical abuse or witness parental violence, on the other hand, did not appear to be at a higher risk for intimate partner violence or poor health, according to Lillian Bensley, PhD, and colleagues at the Washington State Department of Health (2003). The association between childhood abuse and poor health persisted even among women who had not recently experienced partner violence, say the researchers. They suggest the link between abuse and poor health could be due to many factors, including the lingering physical and mental effects of childhood abuse or possibly risky health behaviors. Although the findings suggest a link between childhood experience and adult risks, the researchers say the association might not necessarily lead to health problems in all abused women. “The role of childhood experiences in adult mental health may depend on the life course that follows; other experiences, such as a positive therapeutic experience or a supportive spouse, may be able to counteract these long-term associations,” Bensley and colleagues say. The researchers also found that women younger than 36 had more than 10 times the risk of intimate partner violence and twice the risk of emotional abuse compared to women 46 years and older, regardless of their childhood experiences.

7.6 DOMESTIC VIOLENCE CASES: THE ED PORTAL Approximately 7 percent of victims of nonfatal intimate partner violence sought care in EDs, which represents about 15 percent of those who experience an injury. Less than 1 percent of victims were hospitalized, according to Confronting Chronic Neglect: The Education and Training

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of Health Professionals on Family Violence, published in 2000 by the National Academies of Sciences. Bell, Jenkins, Kpo, and Rhodes (1994) explored whether EDs in a metropolitan county had standard procedures or offered services that address the needs of victims of IPV. Fifty EDs (75 percent of the facilities eligible to participate in the survey) responded to a 55-item questionnaire about their handling of victims of IPV. The researchers discovered that EDs generally rely on patient self-reports to determine whether a patient is a victim of violence. Standard operating procedures for reporting cases to state agencies and referrals for additional services were most likely to exist for areas in which hospitals’ response is mandated by law, such as sexual assault and child abuse. In addition, three fourths of the hospitals had procedures for dealing with elder abuse, an area in which reporting is strongly encouraged. Most direct services received by victims were not specifically targeted to them but were services offered to the general ED population. The most frequent referrals were to rape advocacy groups and battered women’s groups. McGrath et al. (1997) attempted to determine provider behavior in screening for domestic violence and sexual assault, provider training in domestic violence and sexual assault, provider knowledge of available protocols for domestic violence and sexual assault, and provider perception of barriers to intervention. The researchers distributed anonymous surveys to physicians, nurses, and social workers at an adult ED trauma center, an affiliated pediatric ED, and a women’s urgent care center between July and September 1995. Of 207 staff members (59 percent) responding, 54 percent and 68 percent indicated that they never or rarely screen for domestic violence or sexual assault, respectively. Thirty-five percent had received no domestic violence training and 27 percent had received no sexual assault training. Thirty-one percent of the staff had knowledge of existing protocols for domestic violence and 63 percent had knowledge of existing protocols for sexual assault. Providers trained in domestic violence were more likely to screen for domestic violence and sexual assault, and providers trained in sexual assault were more likely to screen for sexual assault and domestic violence. Barriers that the majority of staff experienced in the care of domestic violence or sexual assault victims included frustration that the victim would return to an abusive partner, concerns about misdiagnosis, lack of time, personal discomfort, reluctance to intrude into familial privacy, and lack of 24-hour social service support. Researchers concluded, “Providers surveyed had received little training in and rarely screen for violence, and there are a range of personal and institutional barriers impeding intervention with victims of SA and DV. Institutional changes to enhance training and support providers working in the front line of this epidemic may improve services for victims of violence.”

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Sachs, Baraff, and Peek (1998) desired to quantify the proportion of men and women seen in a university ED for treatment of injuries resulting from intimate partner violence that require reports to law enforcement. A total of 1,516 adult ED patients were asked to complete a written survey instrument, and 1,003 patients (66.2 percent) completed the survey. Two percent of patients reported they presented to the ED for treatment of injuries resulting from IPV. Three percent reported IPV within the last year, and 10 percent reported that they had ever been physically abused by a partner. Six percent of respondents reported that they had ever been threatened with a gun or knife by a partner, 2 percent within the past year. Only the lifetime prevalence of IPV was significantly greater among female patients (15 percent vs. 6 percent). The researchers determined that approximately 2 percent of the sample ED patients required law enforcement intervention for IPV. Stuart (2004) sought to identify risk factors for physical or sexual assault as a result of domestic violence in patients presenting to the ED. The backward prevalence study of two urban teaching hospital EDs measured the one-year period prevalence, acute incidence of ED presentation, and risk factors of domestic physical assault. Of the 1,326 patients (62 percent female) completing the study, 115 reported assault by a partner or ex-partner within the preceding 12 months, and 31 reported domestic physical assault as the cause of their presentation. Risk factors for recent domestic physical assault included female gender, age of less than 25 years, past presentation to an ED for assault, and a past history of child abuse. Stuart found no association between health care utilization or mental illness and the reporting of recent domestic physical assault. Sethi et al. (2004) report that one in three women seeking emergency medical care in inner-city hospitals has suffered domestic violence at some point in her life. The authors base their findings on questionnaire responses from 198 women seeking emergency medical treatment at one inner-city hospital during the course of 22 nursing shifts covering all times of the day and week. None of the women was drunk, confused, or critically ill. The responses indicated that physical assault by a sexual partner was the reason for seeking emergency medical care for 1 percent of the women surveyed. An additional 6 percent said that they had been physically assaulted during the preceding 12 months. One in three of the women (almost 35 percent) confessed that they had been the victims of domestic violence at some point during their life. One in 10 said that the abuse had been life threatening. Three out of four of the women said they did not mind being asked questions about domestic violence while in the ED, and well over half (60.5 percent) felt that they should be routinely asked about these issues. The authors acknowledge the practical difficulties of surveying women in a busy emergency care facility, with the need to protect

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women’s safety and confidentiality. Nevertheless, it might be easier for women to talk about it when directly asked by emergency medical staff, they say. Health professionals need to be more proactive in detecting it, they add: “Few health professionals directly ask about domestic violence and most do not consider it as part of their differential diagnosis. Despite recommendations from professional bodies, little routine health information has been collected or research conducted on the extent to which abused women present to health care services.”

7.6.1 THE HEALTH CARE PROVIDER’S RESPONSE TO DOMESTIC VIOLENCE PRESENTING IN THE ER In 1994, the ENA published a position statement on domestic violence, maltreatment, and neglect. It acknowledges the following: •

• •

• •

Domestic violence consists of all forms of child abuse, violence against intimate partners, and violence against the elderly. Priorities for the domestic violence patient are safety and confidentiality. The victim of domestic violence has a right to be treated in a physical and social environment conducive to compassionate and unbiased care. The emergency nurse is an advocate for the victim of domestic violence. Emergency nurses have the duty to identify and report suspected domestic violence, maltreatment, and neglect.

• • • •

•

•

•

•

•

• •

Therefore, the ENA urges the following: •

•

Emergency nurses take an active role in the development, implementation, and ongoing maintenance of hospital and community protective service teams to ensure consistent and accurate assessments and protection of all individuals and families at risk for domestic violence, maltreatment, and neglect. The early mobilization of social services in suspected or confirmed cases of domestic violence, maltreatment, and neglect.

The ENA supports the following goals related to violence and abuse prevention: • • •

Reduce homicides Reduce maltreatment and maltreatment fatalities of children. Reduce the rate of physical assault by current or former intimate partners.

•

•

Reduce the annual rate of rape or attempted rape. Reduce sexual assault other than rape. Reduce physical assaults. The development and use of routine protocols and procedures for assessment, identification, and referral for survivors of domestic violence, maltreatment, and neglect. Active promotion of a national format for reporting domestic violence, maltreatment, and neglect. Mandatory professional training, curriculum development, and continuing education including the importance of proper documentation and reporting for all health professionals on domestic violence, maltreatment, and neglect. Continued dissemination of information to emergency nurses regarding domestic violence, maltreatment, and neglect, in the form of journal articles, legislative updates, and research activities. The development of outreach programs and appropriate funding for education and prevention programs that help decrease the morbidity and mortality associated with domestic violence, maltreatment, and neglect. Increased public education for the prevention, detection, treatment, reporting, and follow-up of domestic violence, maltreatment, and neglect. Efforts to increase the public’s awareness of neglect as a form of domestic violence. Research efforts in the early identification and treatment of victims of domestic violence, maltreatment, and neglect. Funding for additional personnel and resources, such as advocates and shelters to provide for the protection and treatment of victims of domestic violence. Allocation of funding and resources for the continuation of educational, legislative, and preventive measures regarding domestic violence, maltreatment, and neglect.

The ENA states: By increasing knowledge and understanding through education, the emergency nurse will become more cognizant of the problems of domestic violence, and incorporate the skills of identification and intervention into practice. Nurses are in key positions to assess and detect actual and potential cases of abuse. The emergency nurse must act as the advocate for the victims of domestic violence. Universal screening and identification of victims of domestic violence is the first step to patient advocacy.

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7.6.2 SCREENING PROVIDERS

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In the early 2000s, the U.S. Preventive Services Task Force (USPSTF) published a recommendation statement on screening for family and intimate partner violence, based on its examination of evidence. It updates the 1996 recommendations contained in the Guide to Clinical Preventive Services. In 1996, the USPSTF found insufficient evidence to recommend for or against the use of specific instruments to detect domestic violence. The task force now uses an explicit process in which the balance of benefits and harms is determined exclusively by the quality and magnitude of the evidence. As a result, current letter grades are based on different criteria than those in 1996. (The complete information on which this statement is based, including evidence tables and references, is available through the USPSTF Web site at http://www. preventiveservices.ahrq.gov and through the National Guideline Clearinghouse at http:// www.guideline.gov.). The USPSTF found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse. The USPSTF found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death, and found no existing studies that determine the accuracy of screening tools for identifying family and intimate partner violence among children, women, or older adults in the general population. The USPSTF found fair to good evidence that interventions reduce harm to children when child abuse or neglect has been assessed. The USPSTF also found limited evidence as to whether interventions reduce harm to women, and no studies that examined the effectiveness of interventions in older adults. No studies have directly addressed the harms of screening and interventions for family and intimate partner violence. As a result, the USPSTF could not determine the balance between the benefits and harms of screening for family and intimate partner violence among children, women, or older adults. The USPSTF did not review the evidence for the effectiveness of case-finding tools; however, all clinicians examining children and adults should be alert to physical and behavioral signs and symptoms associated with abuse or neglect. Patients in whom abuse is suspected should receive proper documentation of the incident and physical findings; treatment for physical injuries; arrangements for skilled counseling by a mental health professional; and the telephone numbers of local crisis centers, shelters, and protective service agencies. Several instruments to screen patients for child abuse have been studied, but their ability to predict child abuse or neglect is limited. Instruments to screen for intimate partner violence also have been developed, and although some have demonstrated good internal

consistency (e.g., the HITS instrument: Hurt, Insulted, Threatened, Screamed at; the Partner Abuse Interview; and the Women’s Experience with Battering Scale), none have been validated against measurable outcomes. Only a few screening instruments have been developed to identify potential older victims of abuse or their abusive caretakers. Both of these tools correlated well with previously validated instruments when administered in the community but have not been tested in the primary care clinical setting, the USPSTF stated. The USPSTF reviewed the evidence for the effectiveness of screening procedures and interventions in the primary care setting in reducing harmful outcomes of domestic violence against children, women, and older adults. Because no studies were found that directly addressed the impact of screening on reducing harmful outcomes, the USPSTF examined the accuracy of clinical screening instruments in identifying risk for current or future abuse and the efficacy of clinic-based interventions in reducing harmful outcomes. USPSTF found few screening instruments for the detection of older adults who are the potential victims of abuse or their caretakers. None of the instruments available has been widely validated. No studies have directly addressed the harms of screening and intervention for family and intimate partner violence. False-positive test results, most common in low-risk populations, could compromise the clinician–patient relationship. Additional possible harms of screening could include loss of contact with established support systems, psychological distress, and an escalation of abuse; however, none of these potential harms have been studied. The AAP and the AMA recommend that physicians and other health care providers remain alert for the signs and symptoms of child physical abuse and child sexual abuse in the routine examination. The AMA encourages physicians to inquire routinely about their patients’ domestic violence histories and refer those patients with violence-related problems for medical or communitybased services. The American Academy of Family Physicians notes that family physicians can provide early intervention in family violence through routine screening and the identification of abuse, and recommends that physicians be alert for the presence of family violence in virtually every patient encounter. Taking issue with the USPSTF’s statement that there is insufficient evidence to screen patients for IPV are a number of medical experts and health care providers that assert that less screening and intervention will endanger victims of abuse. Medical leaders insist that the task force used the wrong criteria to assess screening. “We agree that there should be more research exploring the best ways to screen for abuse and help victims,” says Esta Soler, president of the Family Violence Prevention Fund (FVPF):

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But the task force is wrong, and, worse, potentially very harmful. The task force assessed screening for abuse as a medical screen rather than a behavioral assessment tool, which was a mistake. Furthermore, they ignored hundred of studies on this topic, simply because researchers did not use control groups. But highly respected researchers around the world have expressed concern about using control groups because they raise ethical questions about withholding help from patients in danger. The task force should have recognized that and examined existing research more fully.

“We stand by our existing policy of routine inquiry about abuse,” says John Nelson, president of the AMA. “Our experience confirms what common sense tells us: when doctors and other health care providers talk to patients about domestic violence and offer referrals and help to those who are victims, battered patients are more likely to take steps to protect themselves and their children. It would be a tragedy if any provider stopped inquiring about family violence as a result of this recommendation.” “There is strong, clear evidence that health care providers can improve women’s safety by intervening to help those who are battered,” says Debbie Lee, managing director of the FVPF. “Health care providers across this nation, some of who were once reluctant to ask about abuse, can speak to the life-saving benefits of intervention to help victims of domestic violence.” Medical experts criticized the task force for relying on an evidence report that used an overly narrow approach by examining screening for domestic violence as a medical screen rather than a behavioral assessment tool; excluded from their analysis all studies that looked at patients presenting with trauma; discounted a significant body of research; and misapplied a study that examined mandatory reporting for domestic violence to reach conclusions about screening for domestic violence. “Evidence-based medicine is not yet mature regarding behavioral health issues,” says Carden Johnston, MD, FAAP, President of the AAP. “Practitioners have to rely on experiences that work and can be replicated. We know that early screening has real positive effects even though some aspects of emotional and psychological stress of child abuse won’t show up in evidence-based studies. We should never minimize the positive things that we can do to help.” The FVPF’s full response to the task force recommendations can be found at http://www.endabuse.org.

7.6.3 MANDATORY REPORTING CARE PROVIDERS

OF

IPV

BY

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A study conducted in 2000 of 290 women found no difference in the percentage of women reporting domestic violence, whether or not the women were told of a law mandating that physicians report such incidents to a state agency. This study, conducted at the Northern Kentucky

Children’s Advocacy Center at St. Luke Hospital, compared the frequency of domestic violence reported by women who were informed of a state-mandated reporting law to the frequency among women who were not informed of the mandated reporting. In an effort to aid battered women, many states, including Kentucky, have required physicians to report incidents of domestic violence to a state agency. Many physicians are concerned that informing women of the requirement of reporting domestic violence to the state will make these women less likely to reveal the information. The women were screened using a six-question tool in a pediatric office setting. After the screening, the incidence of domestic violence was compared between the two groups. Of the 154 women screened who were not told about the mandatory reporting, 31 percent revealed a domestic violence episode, 17 percent within the last 24 months. Of the 136 women screened who were told about the mandatory reporting to the state, 21 percent revealed a domestic violence episode, only 6 percent within the last 24 months. Overall, the difference is not significant. The incidence of abuse within the past 24 months was significantly lower. “States should consider this study, and others like it, when re-evaluating their policies for the mandatory reporting of domestic violence,” says Robert Siegel, MD, medical director of the Northern Kentucky Children’s Advocacy Center. Sachs et al. (1998) endeavored to assess the effect of California’s 1994 mandatory domestic violence reporting law on Los Angeles Sheriff’s Department dispatches to medical facilities for domestic violence incidents. Researchers analyzed data from the 26,051 dispatches for domestic violence offenses from January 1, 1993, to December 31, 1995. The outcome measures were changes in biweekly department dispatches for domestic violence offenses resulting from the implementation of the mandatory domestic violence reporting law adjusted for seasonal variation and the Nicole Simpson and Ron Goldman murders. The researchers discovered that the percentage of biweekly dispatches to medical facilities for domestic violence offenses did not increase in response to the law. Total domestic violence dispatches increased significantly after the Simpson and Goldman murders but not after passage of the law. Physicians and other health care providers have an important role in the diagnosis, treatment, and documentation of violence-inflicted injuries. These health care professionals can also be legally mandated to report these assault-related injuries to law enforcement. Previous studies have shown that physicians might not be aware of the reporting laws in their state. Houry, Sachs, Feldhaus, and Linden (2002) reviewed the reporting laws for violenceinflicted injuries in adults in the 50 states and the District of Columbia, with particular emphasis on domestic violence. Members of a domestic violence research interest group contacted individual state legislatures regarding

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mandated reporting by health providers of violenceinflicted injuries in adults. This information was then verified by each state’s domestic violence coalition. Statutes regarding child abuse or sexual assault and statutes concerning injuries in incapacitated adults were not included in the study. The researchers found that five states—Alabama, New Mexico, South Carolina, Washington, and Wyoming—have no specific reporting requirements for health care providers treating patients with assault-related injuries. Forty-two states have reporting requirements for injuries resulting from firearms, knives, or other weapons. Twenty-three states have reporting requirements for injuries resulting from crimes. Seven states have statutes that specifically require health providers to report injuries resulting from domestic violence. State laws mandating health care personnel to contact police when treating patients injured as a result of domestic violence are controversial. Attitudes toward these laws have been studied in select groups, but never in a large population-based sample. Sachs et al. (2002) measured support for mandatory reporting among 845 women in 11 cities who participated in a telephone survey assessing risk factors for intimate partner violence. Abused women were oversampled to create equal groups (427 abused and 418 nonabused), and results were presented stratified by abuse status or weighted based on prevalence of abuse among women who were screened. Researchers found that the estimated prevalence of physical violence or threat of physical violence from an intimate partner during the past two years was 11.7 percent. Seventy-two percent of women supported mandatory reporting. Abused women were significantly less likely to support mandatory reporting compared to nonabused women (59 percent vs. 73 percent). Reasons that endorsed support included the belief that victims would find it easier to get help (81 percent) and would like health care personnel to call the police (68 percent). Reasons that endorsed opposition included the belief that victims would be less likely to disclose abuse (77 percent), would resent someone else having control (61 percent), and reporting would increase the risk of perpetrator retaliation (44 percent).

7.6.4 THE PHYSICIAN’S ROLE

IN

IPV CASES

According to Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence (National Academies of Sciences, 2000), a majority of medical schools report the existence of educational content on at least one form of family violence. Most often, this education concentrates on reporting requirements, patient interviewing skills, screening tools, health conditions associated with violence, and services to which victims can be referred. The amount of training varies, from very brief to more extensive. About 95 percent of medical schools report curricular inclusion of material

related to child abuse and neglect, and teaching is both didactic and interactive. When it comes to IPV, schools are trying harder; most instruction is on sexual assault, and the least amount of instruction seems to be on elder abuse. Additionally, family violence training during residency appears to be most common among programs with residents who are considered most likely to encounter victims: pediatrics, obstetrics-gynecology, internal medicine, geriatrics, psychiatry, and emergency medicine. In the August 6, 1996 issue of the Morbidity and Mortality Weekly Report issued by the U.S. Department of Health and Human Services and the CDC, a study looked at family violence education in medical-schoolbased residency programs in Virginia in 1995. In the United States, family violence (e.g., intimate partner violence, child abuse, and elder abuse) is a well-documented social and public health problem that physicians are uniquely positioned to address. However, few schools of medicine or residency training programs provide substantial attention to family violence in their curricula. To assess the status of graduate medical education regarding family violence at Virginia’s three medical schools, Eastern Virginia Medical School, Medical College of Virginia, and the University of Virginia, the Task Force on Violence Education and Awareness for Physicians, established by the Virginia Commission on Family Violence, conducted a survey of these medical schools in 1995. The task force distributed questionnaires to directors of the 69 fully accredited medical-school-based residency programs in the three schools, asking them to indicate the presence in the curriculum of instruction on specific types of family abuse and sexual assault, to indicate whether such teaching was required or elective, and to describe materials and methods used in the curriculum. In addition, the directors were asked to identify faculty at their institution who were experts in the area of family violence and to list the area of their expertise. To increase the likelihood of response to the survey, respondents were informed that only aggregate results would be reported. Therefore, program-specific findings were not included in the report. Of the 69 residency programs surveyed, 48 (70 percent) responded. Of the 48, a total of 26 (54 percent) indicated they included content related to family violence in their curricula. A total of 20 (42 percent) covered child abuse (the content area most frequently covered), 13 (27 percent) covered battered women, and nine (19 percent) covered elder abuse. Whether instruction courses were required or elective varied substantially among the programs. Sixteen of the 20 programs that provided some instruction on child abuse had required courses, as did 10 of the 13 programs that covered battered women and seven of the nine programs that covered elder abuse. In addition, the instructional methods for the existing curricula varied; they included regularly scheduled grand rounds on family violence topics, occasional discussion of these topics as part of noon-

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time conferences, informal instruction from attending physicians during rounds, and “brown bag” series discussions and presentations. Of the 27 experts on family violence identified, 16 had expertise in identifying and treating family-violence-related injuries. Other areas in which experts were identified included child abuse, elder abuse, violence against women during pregnancy, PTSD in children, and community response to violence. No experts were identified in the areas of mental health sequelae of family violence, transgenerational transmission of violence, and violence prevention. The results of the survey described in this report are subject to at least three limitations. First, no attempt was made to contact nonresponding residency programs; survey responses from those programs could have differed from those that did respond. Second, the survey did not have precise criteria for defining presence of family violence instruction in program curricula (e.g., the amount of time spent teaching specific areas of family violence), which could have resulted in overestimating the amount of family violence curricula in place. Finally, no assessment of the quality of curricula was made. The task force used results of this survey to develop five recommendations regarding medical education about family violence in Virginia: 1) formally integrate family violence curricula into medical school and internship/residency programs; 2) use model curricula developed nationally as a base for training programs; 3) develop an in-school assessment tool to track each school’s efforts; 4) have the medical schools, the commission, and the state medical society jointly sponsor a statewide medical-education conference for faculty and other interested persons; and 5) develop statewide mechanisms to coordinate family violence prevention services available through medical, legal, judicial, social services, political, and business agencies and services. These recommendations were adopted by the commission and presented in a report of the commission to the governor and the 1996 General Assembly of Virginia; the General Assembly accepted the recommendations and agreed to continue support for the commission’s activities. In addition, the deans of the three medical schools agreed to collaborate on efforts to more thoroughly and systematically integrate violence education into their residency programs and to develop longitudinal, multidisciplinary instruction at the predoctoral level. In U.S. medical schools and residency programs, family violence education in the curriculum often is brief and not reinforced in residency programs. Most hospitals do not have programs or policies to train and support physicians for work with abuse victims. The study in Virginia illustrates the need for a nationwide assessment of curricula and faculty development in medical school and residency programs and creation of an ongoing reinforcement protocol throughout the health care system, with evaluation instituted at all levels within each program. The CDC

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developed an annotative bibliography of training programs to assist medical training programs, health care organizations, and advocacy groups in identifying curricula and protocols, as well as a framework for evaluating these programs.

7.6.5 DOMESTIC VIOLENCE RECOGNIZED, NOT ALWAYS INVESTIGATED BY MEDICAL STUDENTS In a study in October 2004, most medical students were able to identify domestic violence in a simulated ED encounter. However, say the Temple University researchers who conducted the study, some students didn’t take the next step, inquiring about dangers that might remain once the patient returned home, a step that could help stop the cycle of domestic violence. The study, Medical Interviewing Skills of Fourth Year Medical Students Encountering a Simulated Case of Intimate Partner Violence, was presented at the ACEP annual meeting by Sachin J. Shah, MD, assistant professor of emergency medicine at Temple University School of Medicine. Shah explained, “Students and physicians working in an emergency room may be in a unique position to identify victims of intimate partner violence, a significant public health problem affecting millions of women in the United States. The objective of our study was to determine the ability of fourth-year medical students to identify a victim of intimate partner violence using a simulated emergency department encounter.” Simulated patient encounters are an increasingly common teaching tool for medical students. The exercises help prepare students for what they’ll see when they are physicians and allow them to learn in a controlled teaching environment without consequences. “Our study was designed to measure both how we as teachers are doing and how well the students are learning. What do we need to teach better or emphasize more?” says David Wald, DO, assistant professor of emergency medicine at Temple. In the study, all 196 fourth-year medical students at Temple University School of Medicine completed an exercise with an actor trained to portray a 46-year-old female coming to the ER with lower back pain caused by intimate partner violence. At the end of each 20-minute encounter, the patient documented how the student performed, noting the questions asked, as well as the student’s manner, tone, and professionalism. “In most cases, medical students identified that the actor was portraying a victim of intimate partner violence,” says Shah. “It is unclear whether this occurred by way of routine screening or as a result of deductive reasoning. Even after identification of intimate partner violence, however, few students inquired into the social history of the spouse, whether the patient had ever been sexually abused, whether she wanted to make a report to the police, or whether a firearm was present in the home.” “Some students didn’t go on to ask other pertinent questions, ensuring the safety of the patient at home,”

Interpersonal Violence

Wald says. “These findings will help us shape and improve our curriculum.” As a result of these findings, a discussion regarding domestic violence screening has been incorporated into the emergency medicine clerkship orientation. Hill (2005) asserts that medical schools around the country have initiated ad hoc teaching around family violence issues, especially child abuse and intimate partner violence; however, these activities typically are not integrated with other aspects of the curriculum, or with each other. Consequently, students do not have the opportunity to learn the broader issues related to family violence prevention and intervention. Hill describes how students at the Southern Illinois University School of Medicine participated in an elective to develop a model family violence curriculum encompassing child abuse, IPV, sexual assault, and elder abuse. The activities use standardized patients and resource people, including hotline and shelter staff, legal professionals, and law enforcement. Hill says that family violence teaching in medical schools is merely a first step, and that continuing medical education in violence-related issues must also be available for all clinicians.

7.6.6 PHYSICIANS LESS LIKELY TO SCREEN, BUT MORE LIKELY TO INTERVENE IN DOMESTIC VIOLENCE Despite the fact that only a small percentage of physicians screen new patients for domestic violence compared to other health problems, their interventions are more intensive, according to findings in 2002. “Only 19 percent of physicians surveyed reported screening new patients for domestic violence compared with 98 percent for tobacco use, 90 percent for alcohol abuse, and 47 percent for HIV and sexually transmitted disease risks,” says lead investigator Barbara Gerbert, PhD, from the University of California San Francisco. However, once the problem of domestic violence was identified, the “respondents reported intervening at comparable or greater frequencies—compared with tobacco, alcohol, or HIV/STD risks,” Gerbert reports. Her team’s findings also indicate that physicians spent longer time periods counseling identified domestic violence victims than patients identified as having any of the other three health risks. The study appeared the American Journal of Preventive Medicine. Previous research has shown that between 1.5 million and 3.9 million women are physically abused each year by their intimate partners, with domestic violence affecting an estimated 8 to 14 percent of primary care patients. “In addition to death and immediate trauma, domestic violence results in a number of chronic health problems,” Gerbert explains. These problems include depression, anxiety, and substance abuse. Despite these observations—as well as repeated findings that appropriate screening can be both effective and beneficial and recommendations for

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routine screening from medical organizations and domestic violence experts—Gerbert notes that investigators have repeatedly shown that only a small minority of physicians ask about domestic violence. Previous research shows that physicians’ attitudes and responses regarding domestic violence might affect screening rates, Gerbert and her colleagues note, so they compared physicians’ beliefs and practices on domestic violence and other stigmatized health behaviors for which screening is recommended. The researchers mailed questionnaires to a random, national sample of 1,200 physicians specializing in internal medicine or family practice. Questions on the 32-item survey centered on four health behaviors: domestic violence, tobacco use, alcohol abuse, and HIV/STD risks. The 610 physicians who replied echoed previous reports of particularly low screening rates for domestic violence. At the same time, they reported knowing “less about how to screen for or intervene with domestic violence than the other health risks—and, compared with alcohol abuse and STDs, believe they lack appropriate referral resources,” according to Gerbert and her co-authors. The answers also indicated that although the majority of physicians (86 percent) believe that intervening with domestic violence is an essential or nearly essential part of their role, even more (at least 95 percent) feel that way about the other three problems. Yet physicians’ self-described interventions to domestic violence, once identified, were most intense. Gerbert notes that physicians were far more likely to “provide counseling, arrange for follow-up visits or calls, and refer patients to additional resources for domestic violence victims than–for patients identified with the other three health risks.”

7.6.7 WOMEN’S SHAME STALLS ABUSE DISCLOSURE TO HEALTH CARE PROVIDERS Shame, denial, and fear of others’ reactions keep many abused women from confiding in their physicians, a 1998 Johns Hopkins study of women in Baltimore discovered. Although most of the women queried had sought medical attention for a variety of problems during the past year, only one in three discussed their abuse with doctors. Although half of the women reported positive experiences with their physicians, some noted that the clinicians didn’t listen or seemed uncaring, uncomfortable with the topic of abuse, too busy, or only interested in money. The study, published in the Journal of General Internal Medicine, used questionnaires and focus groups to survey 21 Baltimore-area victims of domestic violence who already were participating in group therapy. Most of the women were single, separated, or divorced, from a mix of income levels. The feelings of fear, shame, and distrust crossed all class lines. “Other studies indicate that as many as 44 percent of women who seek medical attention have been abused at some point in their lives, yet most physicians

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do not routinely screen their patients for abuse,” says Jeanne McCauley, MD, MPH, lead author of the study and a physician advisor for the Johns Hopkins Medical Services Corp. “Our study suggests that many of the barriers to discussing abuse could be overcome by a physician’s understanding of the emotions surrounding abuse and the unique treatment concerns of abused women.” Eighteen of the women (88 percent) sought medical attention during the previous year. Their symptoms, which either began or worsened with abuse, included asthma, hypertension, headaches, eye pain, chest pain, stomach pains, back problems, vaginal bleeding, weight changes, insomnia, depression, and anxiety. Although most women did not recognize an association between abuse and these symptoms, one in three noticed improvement when she left the relationship or discussed it with a health professional. The study also found that: •

•

•

The doctor’s gender was less of a barrier to discussing abuse than whether he or she appeared caring, easy to talk to, and supportive. Domestic violence posters displayed in the medical office helped prompt some victims to speak up. Questionnaires, when administered in private, also helped. Although nearly all of the women who received prescription medications for depression, anxiety, or sleep disturbances benefited from them, many feared addiction or decreased alertness in the presence of an abusive partner.

The fact that all of the women were in group therapy, however, might have introduced bias in the study, McCauley says. “More studies need to be performed to confirm the findings of this study,” she says.

7.6.8 HEALTH CARE PROVIDERS NEED MORE TRAINING TO SPOT AND INTERVENE IN CASES OF DOMESTIC VIOLENCE Research has shown that the prevalence of people, particularly women, being beaten by their partners is high and that such victims are frequent users of medical services. For example, recent studies have shown that the incidence of women seeking care for a domestic violence injury in primary care medical settings ranges between 17 and 25 percent and between 22 and 35 percent in hospital ERs. However, additional research suggests that these women are often not identified as partner abuse victims and are not provided appropriate services based on their unique needs. A study presented in 2000 at the 108th Annual Convention of the American Psychological Association (APA) found that although medical delivery settings provide ample opportunity for domestic violence victims to be identified and assisted, medical personnel often fail to

screen for domestic violence or make appropriate referrals because doctors and nurses aren’t confident in their ability to intervene or provide appropriate help to victims. Other barriers to screening identified by the study were often specific to the individual hospital facilities; lack of private rooms in the ED, for example. Psychologists L. Kevin Hamberger, PhD, of the Medical College of Wisconsin, Deb Pape, PhD, and Debbie Minsky, MSW, of All Saints Health Care Systems, Inc., Racine, Wisconsin, and their co-authors Clare Guse, Jennifer Boerger, and Christine Folsom (2000), measured the amount of training in domestic violence intervention provided to 752 health care professionals in two hospitals in a midsize midwestern city. Through the use of a survey, the Healthcare Provider Survey on Intimate Partner Violence, the health care providers (including doctors, nurses, certified medical assistants, radiology technicians, laboratory technicians, and social workers) were asked about the amount of training they had received, whether they routinely asked patients about violence in their relationships, and what their sense of efficacy was in screening for domestic violence. Fortyeight percent of the study participants reported some prior type of domestic violence intervention training, and 25 percent reported having identified a victim of partner violence in the past year. However, this and other studies have also identified serious barriers to intervention that health providers feel when confronted with a situation involving battering. Based on their study and earlier research, which shows that medical personnel who have received training in how to screen for domestic violence and how to provide help to its victims are much more likely to ask patients about violence in their relationships, the authors recommend that all health care providers receive partner violence education designed to increase their sense of efficacy to identify and help victims of partner violence: “Providing trainees (medical personnel) with didactic information about domestic violence and the health care provider’s role in intervention and prevention, together with role modeling and skill rehearsal, should result in increases in perceived judgments of self-efficacy to screen and help battered victims,” conclude the authors. However, they also emphasized that “one-size training will not fit all.” Their survey shows that different medical personnel are going to need different training, most often dependent on their previous training and experience with domestic violence victims.

7.6.9 NURSES CAN HELP VIOLENCE VICTIMS FIND A SOLUTION In a study of 298 schools of nursing, 100 percent had at least some kind of family-violence-related content in their curricula, but only 53 percent of the schools felt it was adequately addressed (Woodtli & Breslin, 1996). In spite of reports like this, a random sample survey of 1,571

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practicing clinicians in six disciplines, including nursing, demonstrated that more than one third of these clinicians reported no educational content in family violence. On the plus side, attention to the issue is increasing rapidly in the nursing literature. Curriculum content on intimate partner violence has increased with official nursing organization attention to the issue, such as that coming from the ANA and the American Association of Colleges of Nursing (AACN). Studies estimate that as many as 3 million incidents of domestic violence occur worldwide every year. An estimated half of all domestic violence victims report their injuries, so nurses are in a unique position to offer victims of domestic violence real ways to find safety, according to June Sheehan Berlinger, RN, BSN, a survivor of domestic violence, a nurse, and an expert on domestic abuse. She shared her thoughts in an article in Nursing2001. Berlinger, who was the coordinator of clinical programs for the Florida State University Center for Prevention and Early Intervention, says that knowing the tactics used by nurses to identify and assist victims can be helpful to victims or those who suspect a friend might be a victim. Berlinger provides inside details on why people stay in abusive relationships and why abusers feel entitled to control their partners, along with a list of conditions and behaviors that people who are abused often display. “A nurse’s job isn’t to cure a patient or solve her problems,” said Berlinger. “But, she will offer tools and options that will help the patient make her own decisions.” A nurse will also take other appropriate actions to keep the victim safe, such as asking questions about domestic violence only when she and the victim have total privacy. She will make sure that the victim’s chart isn’t left where unauthorized people, such as the abuser, could read it. The nurse will listen without judging, provide emotional support, and help the woman get in touch with a victim advocate. She will also document the woman’s condition carefully and completely. The victim’s patient records can help her successfully prosecute the abuser, resolve child custody issues, or obtain court protection. “A nurse may be the first nonfamily member that a victim turns to for help,” says Berlinger. However, friends or family members can use the same professional approach that nurses take to help a victim of abuse.

icles the responses of 861 21-year-olds on their experiences with violence within their relationships over the past year. Relationships included current or former intimate partners—spouses, boyfriends, or girlfriends. The participants are part of a longitudinal study carried out in New Zealand by University of Wisconsin–Madison psychologists Terrie Moffitt and Avshalom Caspi (1999). “This field is full of surprises,” says Moffitt. “Almost everything we thought we knew isn’t true when we use sound scientific methods to examine it correctly.” The researchers conducted interviews with the participants and used a standardized measure of physical abuse, which includes more than a dozen violent acts from shoving, slapping, or punching to using a knife or gun. “One of the first lessons learned from this study is there are no tidy and distinct groups of victims or perpetrators,” Moffitt said, adding that “mutual violence” between both men and women was a strong trend. However, the consequences of violence against women are more consequential, as women are more likely to be injured by men, she said. Unlike the women, physically abusive men also tend to have other extremely deviant patterns such as drug abuse, chronic unemployment, and dropping out of school. Some of the major findings of the study were as follows:

7.7 THE SCOPE OF PARTNER VIOLENCE

Moffitt suggests that future interventions include the teaching of nonviolent problem solving to teenagers and young parents, and better coordination among police, the judiciary, and psychiatric professionals. The methodology of the study was solid, Moffitt says. The New Zealand study group includes all the males and females born in the city of Dunedin in 1972, so it represents a snapshot of the full population. Researchers also interviewed 360 of the partners independently, and there was 80 percent agreement about the violence reports. Moffitt noted that the results are quite similar to two other national studies of

A study of violence between intimate partners by two University of Wisconsin–Madison psychologists reveals a problem of disturbing scope, with as many as one third of respondents reporting being either victims or perpetrators of physical abuse. Surprisingly, the researchers found that results by gender were not as lopsided as one would presume: Women reported being perpetrators of physical violence toward their partners slightly more than men. The study, released by the National Institute of Justice, chron-

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About 27 percent of women and 34 percent of men in the study reported physical abuse by their partner. The abuse was most prevalent among couples living together. Young adults most likely to be involved in violent relationships are also most likely to be parents. Women who had children by age 21 were twice as likely to be victims of domestic violence, and men who were fathers by age 21 were three times as likely to be physical abusers. The strongest risk factor for both male and female perpetrators was a history of physical aggression before age 15. Male perpetrators were more likely to have backgrounds of poverty and low academic achievement, whereas disturbed family relationships and harsh discipline were common backgrounds for female perpetrators.

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domestic violence that were used for comparison. The Dunedin study participants have been surveyed over a variety of ages during childhood, adolescence, and young adulthood. Although the primary focus of the study was on teen behavioral problems and delinquency, the partner violence question became a natural extension of that earlier work, Moffitt says.

7.7.1 THE THREE FACES

OF

DOMESTIC VIOLENCE

Psychologists at the University of Arkansas’s Center for Research on Aggression and Violence (CRAV) who are currently investigating domestic violence have discovered that men who beat women fall into three main categories of offenders. Such insight could eventually lead to improved treatment methodologies and the possibility of early intervention. Jeffrey Lohr began researching this topic in the mid-1990s in response to the idea that men who batter women might not represent a single homogenous group, but instead might be of several distinct personality types. Along with former graduate student Kevin Hamberger of the Department of Community and Family Medicine at the Medical College of Wisconsin, Lohr investigated the personality characteristics of a group of 800 male court-referred domestic violence offenders in the state of Wisconsin. These men completed several questionnaires, including the Millon Clinical Multiaxial Inventory, designed to detect various character disorders, as well as anger and depression. Statistical analysis of the data revealed three main types of offenders. The first of these groups is composed of psychopathic men. Psychopathy is a personality trait marked by a lack of empathy and poor impulse control. Almost everyone has the trait to some extent, but it appears to be concentrated in some individuals more than in others, Lohr states. These men have frequent run-ins with the law for both violent and nonviolent offenses. Men in this category tend to use drugs and alcohol. They are also more likely to have been abused themselves as children compared to men in the other two groups. The second type of abusers has noncharacterizable personality disorders but appear to be “chronically angry, unhappy, have problems with drugs and alcohol use, but are not psychopathic,” explains Lohr. These men tend to have the most extensive police records for both familyoriented and nonfamily-oriented violence, as well as a myriad of other criminal offenses. “These men tend to be generally violent individuals, and their wives just happen to be there,” Lohr adds. The third distinct type of domestic violence perpetrator comprises individuals with no identifiable character disorders but, unlike the other two groups, the men seem to limit their violence to their families. “They tend to be depressed and unhappy, but do not show obvious or severe personality problems,” says Lohr, referring to the fact that

these men appear to function normally in all other aspects of their lives. “This is the group that we are interested in discovering the psychological variables that lead these otherwise normal men to beat their wives.” These men, like those in the first group, might also display a heightened degree of psychopathy compared to the average population, explains Lohr. Lohr and his colleagues want to investigate exactly how far down the developmental sequence psychopathy extends to investigate its relationship with other personality characteristics and attitudes commonly associated with domestic violence. The main focus of this research remains on the possibility for improved treatment and intervention. As a first step in testing whether these perpetrator categories could be a useful tool for clinicians, 12 individual profiles typifying each category have been sent to trained clinical psychologists to see if they can sort them into the appropriate groups. This is done because those in the position to provide treatment must first find these categories identifiable to be useful. Such categories might ultimately facilitate the treatment of domestic violence offenders by maximizing the match between therapy and client characteristics. “If there are three distinct types of perpetrators, then a ‘one size fits all’ therapy approach might not be the most effective approach,” emphasizes Lohr. “There has really been very little research done in this area, so it will be awhile before any new therapy techniques are actually realized.”

7.7.2 INTIMATE PARTNER VIOLENCE

AND

HOMICIDE

A woman who leaves her abusive partner is at a higher risk of being killed by her partner than a woman who stays with her abuser is, according to a recent report. The risk of homicide increases nine-fold in cases in which a couple separates after living together and when the abuser has a highly controlling personality, says Jacquelyn C. Campbell, PhD, RN, of Johns Hopkins University, and colleagues in the American Journal of Public Health. Abused women are also more likely to be killed by their intimate partner if the partner is unemployed or has access to a gun, or if stepchildren live in the home with the couple. Campbell and colleagues say that physicians should be alert to such factors among their abused female patients. “Under these conditions of extreme danger, it is incumbent on health care professionals to be extremely assertive with abused women about their risk of homicide and their need for shelter,” Campbell says. For instance, “if a woman confides that she is planning to leave her abuser, it is critical to warn her not to confront him personally with her decision,” she says. Homicide is the leading cause of death among African American women ages 15 to 45 and the seventh-leading cause of premature death among women overall. These women are most often killed by an intimate partner and

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the majority of these homicides involve abuse, say the researchers. To identify risk factors related to these deaths, Campbell and colleagues collected data on abusive intimate partner relationships and partner homicides in 11 cities, combing through police records and asking close friends or family members of the victim about her relationship with the abusive partner. The data came from Baltimore; Tampa/St. Petersburg, Florida; New York; Kansas City, Kansas; Kansas City, Missouri; Los Angeles; Chicago; Houston; Wichita, Kansas; Portland, Oregon; and Seattle. Women who never lived with their abusive partners had a significantly lower risk of being killed. The risk was also lower in cases in which the abusive partner had been arrested previously for domestic violence, possibly because arrest can trigger a set of court-ordered protections, Campbell says.

7.7.3 THE DISTURBING TREND

OF

“FEMICIDE”

Health care providers should know about the increase of an alarming trend called femicide, which was documented in a 2004 report, Femicide in New York City: 1995–2002 (New York City Department of Health, 2004). In 1999, homicide was the second leading cause of death among women aged 15 to 19 and 20 to 24 in the United States, with rates of 3.6 and 5.2 per 100,000, respectively. Although men comprised the majority of homicide victims—75 percent between 1976 and 1996—homicide of women, or femicide, represents a significant source of premature mortality among young women in New York City today. However, because male victims constitute the bulk of overall homicide counts, trends unique to homicides of women are often overlooked. When women are killed, they are most often killed by people they know: friends, family members, and intimate partners. For example, in the 20 years between 1976 and 1996, approximately a third of all women who were homicide victims in the United States were killed by current or former intimate partners. The proportion was similar in New York City. In contrast, just 6 percent of male homicide victims were killed by intimate partners. Further, women make up the great majority of all intimate partner homicide victims; in 1998, they constituted 72 percent of all victims. The New York City Department of Health’s Bureau of Injury Epidemiology has collected data on all femicides in New York City since 1990. The goal of this research is to identify risk factors for femicide in New York City to bolster prevention efforts. A 1997 report presented data on femicides that occurred between 1990 and 1994; the most recent report updates the data through 2002. Data was collected on all femicides with victims aged 12 and older from the records of the Office of the Chief Medical Examiner (OCME) of New York City. Records included autopsy, crime scene, and police reports, as well as demographic characteristics of the victim and perpetrator. Data was

collected annually, at least six months after the end of the previous calendar year, to ensure that the OCME records were complete. The data collectors were public health epidemiologists and student interns who were trained on data collection methods, standardized coding techniques, and confidentiality issues. Using both the motive recorded on the police report and information on the victim–perpetrator relationship from the OCME records, cases were categorized as intimate partner femicides and nonintimate-partner femicides. Intimate partner femicides included all homicides characterized as intimate partner femicides, probable intimate partner femicides, secondary intimate partner femicides, and intimate partner accidents. Intimate partner femicides were those in which the alleged perpetrator was either a current or former husband, or an opposite-sex or samesex partner (includes boyfriends, girlfriends, common-law marriages, lovers, etc.). Probable intimate partner femicides were those for which the research team concluded that the perpetrator was an intimate partner, based on relative or informant reporting, regardless of whether the police identified the perpetrator as the intimate partner. Secondary intimate partner femicides were homicides in which the victim was killed during a dispute between two intimate partners; for example, a woman was killed by her stepfather while attempting to interrupt a fight between him and her mother. Intimate partner “accidents” were homicides in which an intimate partner and perpetrator alleged that the homicide was an accident; for example, it was reported that the boyfriend was “playing” with a gun, holding it to the victim’s head, when it went off. Nonintimate-partner femicides include family (nonintimate partner) homicides, family violence “accidents,” homicides committed in association with other crimes (i.e., robbery, drugs, sex crimes), random homicides (such as those caused by stray bullets), justifiable homicides (such as police-perpetrated homicides during an attempted arrest), and other types of homicides. Perpetrators were considered family if they were biological, adopted, step or foster parents, children, siblings, grandparents, cousins, nieces, nephews, or other relatives. In the remaining femicides, the motive was unknown and thus the cases were classified as “unknown.” It is possible that some of these cases were, in fact, intimate partner femicides. The victim–perpetrator relationship was used to categorize intimate partner femicides and family violence femicides, whereas all other motive types (sex crime, narcotics, etc.) were categorized based on the circumstantial information of the crime. This number reflects the possibility that the police misclassify a number of intimate partner femicides each year. It is also possible that the police classify some proportion of these probable intimate partner femicides as such, but after the end of the official data collection period; thus, the OCME records

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did not reflect this classification at the time of data collection. One thousand thirty deaths of women were classified as homicides by the OCME between 1995 and 2002. Of these, 339 were intimate partner homicides, 369 were nonintimate-partner homicides, and 322 were classified as having an unknown motive. On average, intimate partner femicide victims were younger than nonintimate-partner femicide victims (34.2 vs. 41.5). A little more than one third of all intimate partner femicide victims were between the ages of 20 and 29 (34 percent), whereas 29 percent of nonintimate-partner femicide victims were 50 years of age and older. Both findings were statistically significant. Most of the nonintimate-partner femicide victims over 50 years of age were victims of robbery (40 percent) or family violence (31 percent). Women ages 30 to 39 made up the largest age group of all femicide victims, including those with an unknown motive. Twenty-nine percent of all intimate partner femicides were 30 to 39, as were 25 percent of all nonintimate-partner femicides. Almost half (49 percent) of all femicide victims were Black women. Blacks made up the largest percentage of intimate partner femicides (46 percent) and this was true for nonintimate-partner femicide victims as well (50 percent). Among Black women, there is no statistically significant difference between those killed by an intimate partner and those killed by someone else. Among Hispanic and White victims, that difference was statistically significant. A third of all intimate partner femicides were Hispanic women, and 23 percent of nonintimate-partner femicide victims were Hispanic. Among White femicide victims with a known motive, 37 percent were victims of intimate partner femicide and 63 percent were victims of nonintimatepartner femicide. Foreign-born women were significantly more likely to be killed by their intimate partners than U.S.-born women. Fifty-seven percent of foreign-born women were victims of intimate partner femicide. Foreign-born women comprised 35 percent of nonintimatepartner femicide victims and 51 percent of intimate partner victims. Victims of intimate partner femicide were 87 percent more likely than victims of nonintimate-partner femicide to be foreign-born. Lower, middle, and upper median income groups were evenly distributed across intimate versus nonintimate-partner femicides. Each median income group comprised approximately one third of all femicides (including unknowns). Although all three groups were evenly distributed by motive, the lower and middle groups consist of relatively poor women (with an income of less than $34,900), indicating that a disproportionate number of poor women were victims of femicide. Women who tested positive for drugs were less likely to be killed by their intimate partners (40 percent) than victims of other crimes (60 percent). Victims of intimate partner femicide were 45 percent less likely to test positive for drugs (including

Forensic Nursing

alcohol) than nonintimate-partner femicides. Most femicide victims for whom a motive was known were killed in their own home (59 percent); however, victims of intimate partner femicide were 2.9 times more likely than victims of nonintimate-partner femicide to be found in their own residence. Of those femicide victims found outside, 76 percent were victims of crimes other than intimate partner violence. A firearm was used in one third of all femicides. Femicides committed with a firearm made up the largest percentage of method used for intimate partner femicides (40 percent) as well as nonintimate-partner femicides (32.2 percent). One third of all intimate partner femicide victims were stabbed by their assailant compared to 17.4 percent of all nonintimate-partner femicide victims. Women who were stabbed to death were 2.1 times more likely to have been killed by an intimate partner than someone who was not an intimate partner. Victims of intimate partner femicide were less likely than nonintimate-partner femicides to be victims of rape or sexual assault. Of those women who were sexually assaulted, 86 percent were victims of nonintimate-partner femicide. The majority of all perpetrators whose gender is known are male (94.3 percent). Only 4 percent of the femicides in which the gender of the perpetrator was known were committed by women, and only three of the intimate partner homicides were committed by women. There was a correlation between intimate partner femicides and perpetrators who committed suicide. Of those perpetrators who committed suicide, 87 percent were intimate partners and 13 percent had some other relationship to the victim. Perpetrators who committed suicide were 8.4 times more likely to have killed an intimate partner than to have killed someone else. Finally, the rate of intimate partner femicide remained fairly stable from 1995 through 2002, with a slight increase in 2002 indicating that intimate partner femicide remains a major public health issue in New York City. Interventions that have contributed to an overall decrease in femicides do not appear to have contributed to a decrease in femicides perpetrated by intimate partners. This study demonstrates that young, foreign-born, and minority women are overrepresented among intimate partner femicide victims. To reduce deaths among these population subgroups, public health officials must fund research-driven programs, founded on identifying risk factors for serious and lethal intimate partner violence.

7.8 A NATIONAL CONSENSUS ON DOMESTIC VIOLENCE In the last 15 to 20 years, an increasing number of health care providers have been given the tools they need to identify and address the needs of victims of domestic violence, also known as intimate partner violence. At some

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point in their lives, most Americans see a health care provider; therefore the health care setting offers a critical opportunity for early identification and even primary prevention of abuse. Studies have demonstrated that assessing for intimate partner violence in medical settings has been effective in identifying women who are victims and that patients are not offended when asked about current or past incidents of intimate partner violence. Numerous professional health care associations have issued position statements to their members describing the impact of IPV on patients and suggesting strategies for assessment and identification of abuse. These statements represent important steps in raising awareness about intimate partner violence in health care settings. Generally, however, they offer neither specific guidelines for intervening and responding, nor criteria that promote the utilization and evaluation of recommended practice. To help fill this void, the FVPF assembled a significant body of thought titled National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Healthcare Settings. For more than two decades, the FVPF has worked to end violence against women and children around the world. Instrumental in developing the landmark VAWA passed by Congress in 1994, the FVPF has continued to break new ground by reaching new audiences, promoting leadership within communities to ensure that violence prevention efforts become self-sustaining, and transforming the way that health care providers, police, judges, employers, and others address violence. The FVPF is a national nonprofit organization committed to mobilizing concerned individuals, allied professionals, women’s rights groups, civil rights groups, other social justice organizations, and children’s groups through public education and prevention campaigns, public policy reform, model training, advocacy programs, and organizing. This important consensus document gathers recommendations from some of the leading experts in the field, and should be required reading for any forensic nurse wishing to expand his or her knowledge base of IPV. The guidelines offer specific recommendations for assessing for and responding to IPV that can be applied to multiple health settings. The next section examines the consensus document to glean important suggestions for the health care provider. Intimate partner violence is a pattern of assaultive and coercive behaviors that can include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats. These behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent, and are aimed at establishing control by one partner over the other. Intimate partner violence is a health problem of enormous proportions. It is estimated that between 20 percent and 30 percent of women and 7.5 percent of men in the United States have been physically or sexually abused by

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an intimate partner at some point in their adult lives. Heterosexual women are five to eight times more likely than heterosexual men to be victimized by an intimate partner. From 1993 to 1998, victimization by an intimate accounted for 22 percent of the violent crime experienced by females and 3 percent of the violent crime sustained by males. Women aged 16 to 24 experience the highest per-capita rate of intimate partner violence. For adolescents, the rates of experiencing some form of dating violence vary from 25 percent to 60 percent. Although studies indicate that boys and girls might accept physical and sexual aggression as normative in dating and intimate partner relationships, adolescent females are more likely to receive significant physical injuries than boys and are more likely to be sexually victimized by their partners. No one is immune from the risk of abuse. The National Center on Elder Abuse estimates that 818,000 elderly Americans were victims of domestic abuse in 1994. There are far fewer data on lesbian, gay, transgender, and bisexual (LGTB) victimization. However, the available literature suggests similarly high rates for LGTB adolescent and adult populations with higher rates in male same-sex relationships than female. Intimate partner violence occurs in every urban, suburban, rural, and remote community; in all social classes; and in all ethnic and religious groups including immigrant and refugee populations. Consequently, all health care settings and professionals providing care to patients are treating patients affected by intimate partner violence and are in a position to identify and intervene on behalf of victims. The estimates of children exposed to intimate partner violence vary from 3.3 million to 10 million per year, depending on the specific definition of witnessing violence, the source of interview, and the age of child included in the survey. In the Adverse Childhood Experiences Study, conducted on a large sample of members (30,000 adults) of the Kaiser Health Plan in California, 12.5 percent of respondents indicated childhood exposure to intimate partner violence and 10.8 percent indicated a personal history of child abuse including physical, sexual, and emotional abuse. This research and other studies indicate that children who witness intimate partner violence are seen with both frequency and regularity in the health care system as children and as adults.

7.8.1 HEALTH EFFECTS VIOLENCE

OF INTIMATE

PARTNER

In addition to injuries sustained by women during violent episodes, physical and psychological abuse are linked to a number of adverse medical health effects, including arthritis, chronic neck or back pain, migraine or other types of headache, STIs (including HIV/AIDS), chronic pelvic pain, peptic ulcers, chronic irritable bowel syndrome, and frequent indigestion, diarrhea, or constipation.

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Six percent of all pregnant women are battered and pregnancy complications, including low weight gain, anemia, infections, and first and second trimester bleeding, are significantly higher for abused women, as are maternal rates of depression, suicide attempts, and substance abuse. Optimal management of other chronic illnesses such as asthma, HIV/AIDS, seizures, diabetes, gastrointestinal disorders, and hypertension can be problematic in women who are being abused or have been abused in the past. Often the perpetrator controls the victim’s access to and compliance with health protocols. Emerging research shows that women who are abused are less likely to engage in important preventive health care behaviors such as regular mammograms, and they are more likely to participate in injurious health behaviors including smoking, alcohol abuse, and substance abuse. In many controlled studies, intimate partner violence significantly increases the risk for serious mental health consequences for victims, including depression, traumatic and posttraumatic stress disorder, anxiety, and suicidal ideation. The health consequences of abuse can continue for years after the abuse has ended. Intimate partner violence can also result in homicide; in 1996, 1,800 murders were attributed to intimates. More than 100 studies have explored the short- and long-term effects of intimate partner violence on children. In 30 percent to 60 percent of families affected by intimate partner violence, children are also directly abused. Children exposed to intimate partner violence, particularly chronic abuse, often show symptoms associated with PTSD. One study found that a child’s exposure to intimate partner violence (without being directly assaulted) was sufficiently traumatic to precipitate moderate to severe symptoms of PTSD in 85 percent of the children surveyed. Although physical health problems have seldom been measured in children exposed to intimate partner violence, one study found that they are more likely to exhibit physical health problems including chronic somatic complaints, and behavioral problems such as depression, anxiety, and violence toward peers. Another study found that exposed children were also more likely to attempt suicide, abuse drugs and alcohol, run away from home, engage in teenage prostitution, and commit sexual assault crimes. There is a growing body of research regarding the impact of violence on early brain development that could have implications for children growing up in violent homes. There is an urgent need to address family violence over the life span because the health effects of victimization often persist for years after the abuse has ended. Adults who were abused as children, witnessed intimate partner violence, had a parent with a mental illness, or witnessed parental substance abuse are at significantly high risk for obesity, heart disease, hepatitis, diabetes, depression, and suicide. These adverse childhood experiences frequently cluster in households and have a cumu-

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lative effect: The more adverse exposures in a household, the higher the likelihood of long-term health problems as an adult.

7.8.2 IDENTIFYING AND RESPONDING TO ABUSE CAN MAKE A DIFFERENCE The National Consensus says that the health care system plays an important role in identifying and preventing public health problems. Models developed to identify other chronic health problems can effectively be applied to intimate partner violence. Routine inquiry, with a focus on early identification of all victims of intimate partner violence whether or not symptoms are immediately apparent, is a primary starting point for this improved approach to medical practice for intimate partner violence. Regular, face-to-face screening of women by skilled health care providers significantly increases the identification of victims of intimate partner violence, as well as those who are at risk for verbal, physical, and sexual abuse. Routine inquiry of all patients, as opposed to indicator-based assessment, increases opportunities for both identification and effective interventions, validates intimate partner violence as a central and legitimate health care issue, and enables providers to assist both victims and their children. When victims or children exposed to intimate partner violence are identified early, providers might be able to break the isolation and coordinate with domestic violence victim advocates to help patients understand their options, live more safely within the relationship, or safely leave the relationship. Expert opinion suggests that such interventions in adult health settings could lead to reduced morbidity and mortality. Talking with patients about intimate partner violence provides a valuable opportunity for providers to learn about their experiences with abuse. Battered women report that one of the most important aspects of their interactions with a physician was being listened to about the abuse. Even if a patient chooses not to disclose being abused, the provider’s inquiry can often communicate support and increase the likelihood of future discussion of the issue. The National Consensus says that all health care settings, including acute-care hospitals, clinics, and primary care environments, are prime settings for the identification of domestic violence and intimate partner violence cases. It says that inquiry and initial response should be conducted by a health care provider who: •

•

Has been educated about the dynamics of intimate partner violence, the safety and autonomy of abused patients, and elements of culturally competent care. Has been trained how to ask about abuse, to provide information about intimate partner

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• • •

violence and local community resources, and to intervene with identified victims. Is authorized to record in the patient’s medical record. Has established a relationship or some trust with the patient in a primary care setting. Has a clearly defined role in a specialty, urgent care, or emergency setting.

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•

•

The inquiry should not be made if: •

7.8.3 CONDUCTING THE INTIMATE PARTNER VIOLENCE INQUIRY According to the National Consensus, health care providers should ask patients about current and lifetime exposure to intimate partner violence victimization, including direct questions about physical, emotional, and sexual abuse. Recipients of this inquiry should be all adolescent and adult patients regardless of cultural background, as well as parents or caregivers of children in pediatric care. The intimate partner violence assessment should be: • • • • •

•

•

Conducted routinely, regardless of the presence or absence of indicators of abuse. Conducted orally as part of a face-to-face health care encounter. Included in written or computer-based health questionnaires. Direct and nonjudgmental, using language that is culturally and linguistically appropriate. Conducted in private: no friends, relatives (except for children under the age of 3), or caregivers should be present. Confidential: prior to inquiry, patients should be informed of any reporting requirements or other limits to provider–patient confidentiality. Assisted, if needed, by interpreters who have been trained to ask about abuse and who do not know the patient or the patient’s partner, caregiver, friends, or family socially.

The inquiry for past and present intimate partner violence victimization should take place: • • • •

•

As part of the routine health history (e.g., social history and review of systems). As part of the standard health assessment (or at every encounter in urgent care). During every new patient encounter. During periodic comprehensive health visits (assess for current intimate partner violence victimization only). During a visit for a new chief complaint (assess for current intimate partner violence victimization only).

At every new intimate relationship (assess for current intimate partner violence victimization only). When signs and symptoms raise concerns or at other times at the provider’s discretion.

• •

The health care provider cannot secure a private space in which to conduct inquiry. There are concerns that assessing the patient is unsafe for either patient or provider. The provider is unable to secure an appropriate interpreter.

If the inquiry does not occur, the health care provider should note in the medical record that the inquiry was not completed, and schedule a follow-up appointment (or if in an urgent-care setting, refer the patient to a primary care provider). Also, the health care provider should have on hand posters, safety cards, and patient education materials about intimate partner violence available in exam or waiting rooms, bathrooms, or on discharge instructions. 7.8.3.1 Conducting the Health and Safety Assessment The goals of the assessment are to create a supportive environment in which the patient can discuss the abuse, enable the health care provider to gather information about health problems associated with the abuse, and assess the immediate and long-term health and safety needs for the patient to develop and implement a response. Assessment should take place immediately after disclosure, and repeat or expanded assessments should occur during follow-up appointments with health care providers and domestic violence victim advocates. According to the National Consensus, for the patient who discloses current abuse, assessment should include, at a minimum, the following questions: • • • • • • • • •

Are you in immediate danger? Is your partner at the health facility now? Do you want to (or have to) go home with your partner? Do you have somewhere safe to go? Have there been threats or direct abuse of the children (if he or she has children)? Are you afraid your life might be in danger? Has the violence gotten worse or is it getting scarier? Is it happening more often? Has your partner used weapons, alcohol, or drugs? Has your partner ever held you or your children against your will?

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• •

Does your partner ever watch you closely, follow you, or stalk you? Has your partner ever threatened to kill you, himself or herself, or your children?

If the patient states that there has been an escalation in the frequency or severity of violence, that weapons have been used, or that there has been hostage taking, stalking, homicide or suicide threats, health care providers are advised to conduct an assessment for homicide or suicide. To assess the pattern and the history of current abuse, the following questions should be asked: • • • •

• •

How long has the violence been going on? Have you ever been hospitalized because of the abuse? Can you tell me about your most serious event? Has your partner forced you to have sex, hurt you sexually, or forced you into sexual acts that made you uncomfortable? Have other family members, children, or pets been hurt by your partner? Does your partner control your activities, money, or children?

If a patient says there have been no episodes of intimate partner violence, the health care provider should respect the patient’s response, letting him or her know that help is available should the situation ever change. Assessment should be made again at previously recommended intervals. If the health care provider believes the patient might be at risk, discuss the specific risk factors and offer information and resources in exam and waiting rooms. Providing intervention services and advocacy might be done by the health care provider or by the advocate. Interventions will vary based on the severity of the abuse, the patient’s decisions about what he or she wants for assistance at that time, and if the abuse is happening currently. For all patients who disclose current abuse, providers should provide validation by listening nonjudgmentally, provide information, respond to the patient’s safety issues, and make referrals to local resources.

Perpetrators who discover that a victim has sought care might retaliate with further violence. Employers, insurers, law enforcement agencies, and community members who discover abuse might discriminate against a victim or alert the perpetrator. It is imperative that policy, protocol, and practice surrounding the use and disclosure of health information regarding victims of intimate partner violence should respect patient confidentiality and autonomy and serve to improve the safety and health status of victims. The federal medical records privacy regulations issued in August 2002 (which went into effect on April 14, 2003) have specific implications for victims of violence. 7.8.3.3 Documentation The National Consensus states that documentation should be conducted by a health care provider who is authorized to record in the patient’s medical record. Providers should document the patient’s statements and avoid pejorative or judgmental documentation (e.g., write “patient declines services” rather than “patient refuses services,” and “patient states” rather than “patient alleges”). Health care providers should document relevant history, including the following: • • • •

•

• • •

7.8.3.2 Reporting Cases of Intimate Partner Violence

•

Some states have requirements to report current victimization to law enforcement or to social services. Health care providers should learn applicable statutes in their state, and if they practice in a state with a mandated reporting law, they should inform patients about any limits of confidentiality prior to conducting an assessment. Regarding confidentiality, the National Consensus emphasizes that inappropriate disclosure of health information could violate patient–provider confidentiality and threaten patient safety.

•

Chief complaint or history of present illness. Details of the abuse and its relationship to the presenting problem. Any concurrent medical problems that might be related to the abuse. For current intimate partner violence victims, a summary of past and current abuse including social history, relationship to abuser, and abuser’s name, if possible. Patient’s statement about what happened, not what led up to the abuse (e.g., “boyfriend John Smith hit me in the face” not “patient arguing over money”). Date, time, and location of incidents where possible. Patient’s appearance and demeanor (e.g., “tearful, shirt ripped” not “distraught”). Any objects or weapons used in an assault (e.g., knife, iron, closed or open fist). Patient’s accounts of any threats made or other psychological abuse. Names or descriptions of any witnesses to the abuse.

Health care providers should document the results of physical examination, including the following: •

Findings related to intimate partner violence, neurological, gynecological, and mental status exam if indicated.

Interpersonal Violence

• • •

If there are injuries (present or past), describe type, color, texture, size, and location. A body map or photographs to supplement written description. A consent form prior to photographing patient. Include a label and date.

Health care providers should document laboratory and other diagnostic procedures, including recording the results of any lab tests, X-rays, or other diagnostic procedures and their relationship to the current or past abuse. Health care providers should document the results of assessment, intervention, and referral: •

• •

Record information pertaining to the patient’s health and safety assessment including your assessment of potential for serious harm, suicide, and health impact of intimate partner violence. Document referrals made and options discussed. Document follow-up arrangements.

If the patient does not disclose intimate partner violence victimization, the health care provider should document that assessment was conducted and that the patient did not disclose abuse. If you suspect abuse, document your reasons for concern (i.e., “physical findings are not congruent with history or description,” or “patient presents with indications of abuse”). 7.8.3.4 Continuity of Care for the Patient At least one follow-up appointment (or referral) with a health care provider, social worker, or domestic violence victim advocate should be offered after disclosure of current or past abuse. At every follow-up visit with patients currently in abusive relationships, the health care provider should review the medical record and ask about current and past episodes of intimate partner violence, as well as communicate concern and assess both safety and coping or survival strategies. For current and previous victims, the health care provider should ensure that the patient has a connection to a primary care provider, and coordinate and monitor an integrated care plan with communitybased experts as needed. 7.8.3.5 Challenges for the Health Care Provider When Screening Patients for Intimate Partner Violence The National Consensus acknowledges that regularly assessing all patients for intimate partner violence victimization raises additional policy and practice issues for providers and there is debate in the field about appropriate

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responses. Those opposed to these policies assert that the risks of alerting perpetrators to the practice of assessing for intimate partner violence outweigh the benefits. There are concerns that perpetrators might limit their partners’ access to health care, might threaten victims who disclose, or might learn about safety planning materials, which could ultimately undermine victim safety. Proponents of policies to assess men and women assert that because men in same-sex relationships experience intimate partner violence at equal rates as women in heterosexual relationships, and some men in heterosexual couples experience abuse, it is critical to identify and assist as many victims as possible. Proponents also argue that determined perpetrators can already access safety planning materials and that assessing all patients offers unparalleled opportunities for abuse prevention. Still others maintain that because the majority of victims are women, providers should begin by assessing all female patients and integrate assessing men as a second step, after gaining more experience in assessment for victimization and developing policies to address some of the difficult practical concerns that are raised when assessing all patients. Frequently, it might be difficult to assess who the victim is, as the accounts of one or both parties could lead to confusion about the incident. Male perpetrators often claim victimization to avoid consequences or as a tactic to further control victims. Because the majority of intimate partner violence perpetrators are male, assessing men increases the likelihood of assessing perpetrators who might claim they are victims. There is not sufficient experience with female perpetrators of violence to know if this is also true of them. Victims might take the blame for the abuse because their partners have told them repeatedly that the problems in the relationship are their fault or because they used violence or other tactics in self-defense. Both parties might use physical force in an incident. Whether the patient is viewed as a victim or perpetrator will influence the health care provider’s response and could lead to inappropriate treatment: •

•

•

A victim who takes the blame for the abuse might prevent providers from offering support and information about intimate partner violence. Perpetrators who falsely claim they are victims might lead providers to share safety planning strategies with them, inadvertently colluding and undermining victims’ safety planning efforts. What is recorded in the medical record by the health care provider can have legal ramifications for the victim, particularly in divorce, custody, or other legal cases.

Although it is not the role of the health care provider to determine if the patient is telling the truth, the provider should take care in evaluating the patient’s information

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and in identifying whether or not the patients is a victim of intimate partner violence, just as they take care in evaluating other patients’ reports of health concerns. Understanding the definition of intimate partner violence and being skilled in behavioral inquiry assists providers in making accurate identification of victimization. Prior to implementing a protocol to assess all patients for abuse, providers should be trained on the dynamics of intimate partner violence and perpetrator issues, including the context and intent of abuse and how the abuse affects both the perpetrator and the victim. Training should include but not be limited to what is known about perpetrator and victim dynamics. The following behaviors are characteristic of perpetrators: • • • • • • • • •

They often control access to money, property, and other shared commodities. They are often notably jealous of friends, family, co-workers, and others. They are often scornful of their partner’s perspective. They can use various forms of status to claim authority, knowledge, or power. They often minimize or explain their behavior, make excuses, or become defensive. They are often vague about violent incidents. The might have a documented prior use of violence. They often have offensive wounds (i.e., scratches or bite marks when injuries are present). They use physical force against people or property.

Victims often display these characteristics: • • •

• •

• • •

They are often fearful of their partners. They are often not allowed access to family, friends, or other support networks. They often experience reduced autonomy, and when they exercise autonomy, there are negative or abusive consequences. They often feel guilty or wonder if they are to blame for their partner’s violence. They might experience problems sleeping, chronic pain, gastrointestinal disorders, nervousness, depression, or signs of PTSD. They are more likely to have more serious injuries (injuries to the head, neck, and torso). They can often articulate what precipitated specific incidents or the progression of violence. They have been told by others (family, friends, etc.) about the concern for the patient’s safety.

7.9 THE FAMILY JUSTICE CENTER CONCEPT Other chapters have described the average plight of the victim of IPV or sexual assault; the person who is bounced back and forth (often across town) among health care providers, advocates, and law enforcement; and often made to wait for long periods of time while the reporting and documentation process unfolds. There had to be a better way to serve victims of abuse, thought then San Diego City Attorney Casey Gwinn, who, on October 10, 2002, with then San Diego Police Chief Dave Bejarano, launched the San Diego Family Justice Center (SDFJC). The concept of the one-stop center received full support from elected officials from the city and county of San Diego, corporate and community leaders, nonprofit agencies, state and federal governmental agencies, foundations, and individuals from the community. The SDFJC was a new community initiative designed to help domestic violence victims and their children by bringing together 120 professionals from 24 agencies under one roof. For the first time in San Diego history, victims had easy access to advocates, police officers, prosecutors, probation officers, civil attorneys, counselors, doctors, and other professionals in one location in downtown San Diego. The center’s goals were simple: to provide more services from one location, reduce child abuse and domestic violence incidents, hold batterers accountable, and ultimately be the first large-city jurisdiction in the United States to see domestic violence homicides eliminated. Organizers of the SDFJC knew that, despite increased efforts over the last decade, domestic violence continued to be a significant problem throughout San Diego. Each year, law enforcement agencies document approximately 25,000 domestic violence incidents within the city and county of San Diego. This figure is even more alarming when one considers that experts estimate that only 25 percent of domestic violence cases are actually reported. Prior to the SDFJC, the criminal justice system made it difficult for victims to seek help and unintentionally wore them down, its supporters say. Victims were often required to travel from location to location to seek services that were scattered through the city and county. Victims had to tell their story repeatedly to law enforcement, courts, legal aid, medical professionals, transportation officials, housing, social services, mental health, rehabilitation, financial assistance, and many more entities. Prior to the launch of a one-stop concept, the criminal justice system made it easier for victims to become frustrated and ultimately give up on seeking the assistance they needed. The old system, many believed, allowed sophisticated or seasoned offenders to slip through the cracks and avoid accountability due to the high volume of cases, lack of resources, and a lack of communication among the various

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professionals involved in these cases. It became evident that sweeping changes were necessary to bring perpetrators to justice and to resolve the fractured nature of the provision of services to victims. A coordinated community response was needed. Diana Faugno, RN, BSN, CPN, FAAFS, SANE-A, district director of forensic health services at PalomarPomerado Hospital in North County, San Diego, recalls early discussion of a one-stop shop concept for her county: I remember talking to Assistant City Attorney Gael Strack years ago and saying, “Gael, here’s the vision: picture an umbrella; hang all those hooks under it when you are looking at forensic services, whether it is domestic violence, sexual assault, child abuse or elder abuse—they all need to be under one umbrella and we have to get out of those individual silos.” I know we like to stay in them because we have our comfort zones, but the interpersonal violence won’t stop; it crosses everything that we do here, and that’s part of the problem.

The center provides a combination of services and interventions from one location to help victims and offenders break the cycle of violence and develop healthy relationships. A collaborative effort also provides more support to victims and children involved in domestic violence through improved case management and a more fluid exchange of information and resources. Bridging existing gaps improves victims’ accessibility to services and resources, and makes the entire process of reporting a domestic violence incident much less overwhelming for the victims and children involved. Not only does the center assist victims, it dramatically improves the quality of police investigations and ultimately increases the number of convictions of domestic violence perpetrators. By increasing the conviction rates, there is also an increase in the number of perpetrators who complete the mandatory 52-week domestic violence rehabilitation program. Supporters of the SDFJC say that the combination of this extensive counseling for perpetrators, in conjunction with the empowerment and education of victims and children, works in a synergistic fashion to reduce the rates of child abuse and domestic violence recidivism in San Diego. The scope of the SDFJC is far reaching; phasing plans include offering comprehensive medical and legal services; counseling to victims and children; links to juvenile, family, and criminal courts; as well as access to on-site professionals such as child protective service workers, probation, parole, and border patrol officers, advocates, and the Kids in Court program. Intervention initiatives include case management and risk assessments for every case, providing increased supervision of repeat offenders, assisting high-risk victims, providing meaningful probation for misdemeanor offenders, providing a systemwide audit, apprehending fugitives, and improving investigation

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techniques. Prevention initiatives include assisting pregnant victims exposed to domestic violence, outreach efforts to young adults and underserved victims, and increased community training. The San Diego medical, legal, and law enforcement communities had been planning and preparing for the establishment of the SDFJC since 1989, when the concept first became the subject of a wide variety of community forums, focus groups, and strategic planning meetings. Organizers visited other sites to see what worked and what didn’t, and a feasibility study was conducted by the San Diego Police Department. As a result of these efforts, a model that was right for the demographics of San Diego was developed. This model includes best practices, local partners, proven strategies, innovative programs, and an ideal site. San Diego knew it had the expertise, skills, and partnerships to ensure the success of this important project. During the last 15 years, San Diego has developed a comprehensive community response to domestic violence. This response included the creation in 1989 of the countywide San Diego Domestic Violence Council, comprised of more than 200 agencies, which functions through a network of 14 working committees. As part of its vision and mission, the council developed many protocols, including the San Diego Domestic Violence Law Enforcement Protocol, a medical facilities protocol, treatment standards, and much more. San Diego also established specialized domestic violence units in the City and District Attorney’s offices, city and county law enforcement, probation, and the Superior Court. This collaborative regional effort resulted in strong community partnerships and significant reductions in reported incidents of domestic violence and homicides. In 1986, there were fewer than 5,000 cases and 30 domestic violence homicides. In 1991, the city faced 11,739 cases and 22 homicides. In 2001, it had 10,666 cases and 10 homicides, including the deaths of two children and one unborn child. The SDFJC has some restrictions and jurisdictional limitations, however. The San Diego Police Department has jurisdiction over only criminal (felony and misdemeanor) cases that occur within the city of San Diego; the City Attorney’s office has jurisdiction to prosecute misdemeanor cases that occur only within the incorporated cities of San Diego and Poway. At its inception, the SDFJC was housed in a 27,000square-foot space spread out over three floors. Floor plans were specifically developed to handle the volume, put victims and children at ease, and provide accessible services. The center has special waiting rooms for victims and children, medical facilities, and state-of-the-art interview rooms. There are multiple large and small conference rooms to allow for community meetings and training. The center received substantial funding from government, public, and private entities in its first year, and sustainability is important for the SDFJC to continue to provide these

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crucial services. The center’s staff and board continue to take aggressive steps to ensure the longevity of the project, including cultivating funding from the city and the county. They also are seeking grants at the local, state, and federal level. Protracted financial security arrived in 2003 when Attorney General John Ashcroft announced that $30 million had been earmarked for 15 communities pursuing the family justice center concept. These communities were selected for funding under President George W. Bush’s Family Justice Center Initiative, which was designed to prevent and respond to violence against women. The initiative, unveiled by President Bush in October 2003, was an unprecedented pilot program charged with making a victim’s search for help and justice more efficient and effective by bringing professionals who provide an array of necessary services together under one roof. The Justice Department’s Office on Violence Against Women (OVW) has taken the lead in this pilot program to develop comprehensive domestic violence victim service and support centers in these 15 communities across the country. “The Family Justice Center Initiative Awards will make a tremendous difference for women in these communities who are victimized by domestic violence, allowing those who desperately need help to find it in one place,” said Ashcroft. “The cause of justice is served not only when we prosecute criminals, but also when we reach out to the victims of crime. The Family Justice Centers will ease their burden and demonstrate that the most compassionate way of helping victims can also be the best and most effective way.” “Offering centralized, comprehensive services to domestic violence victims is the coordinated community response at its best,” said Office on Violence Against Women Director Diane M. Stuart. “Whether it’s obtaining a protection order, talking to an advocate, or meeting with a prosecutor, these centers will enable victims to get the assistance they need to put their lives and their children’s lives back on track.” Often, the services designed to help these victims are uncoordinated and scattered throughout communities. The Family Justice Center Initiative sites are designed to bring together advocates from nonprofit, nongovernmental domestic violence victim services organizations, law enforcement officers, prosecutors, probation officers, governmental victim assistants, forensic medical professionals, civil legal attorneys, chaplains, and representatives from community-based organizations into one centralized location. The 15 newest family justice centers were encouraged to look to those centers pioneered in San Diego, Indianapolis, and Hennepin County, Minnesota, for the comprehensive development and creation of their own facilities. U.S. Justice Department efforts will be further supported by its partners from the Department of Health and Human Services, Department of Agriculture, Department of Defense, Department of Education, Department

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of Housing and Urban Development, and Department of Labor. “The problem with these big justice centers is that it takes tremendous resources to maintain them,” Diana Faugno adds, tapping into one of the main reasons so many fledgling centers are seeking local, state, and federal assistance. “Expenses are everywhere—running the program, paying the staff . . . those huge expenses are what kills everyone.” At the announcement of the $20 million funding in October 2003, President Bush acknowledged the numerous difficulties victims encounter in the reporting process, and how family justice centers can alleviate or eliminate completely any unnecessary waiting times, paperwork, and redundant examinations and questionings. “Too often, the services designed to help victims are uncoordinated and scattered throughout communities,” Bush stated. “Imagine what it would be like if you were an abused person trying to find help and you went from one place to another. With laws and police and all the rules and regulations of a free society, it must be confusing and disheartening. The victim has been so traumatized, and then she has to tell her story over and over again, which repeats the trauma. There’s a better way to do this. There’s a better way to help people who need help in our society.” He also acknowledged the hard work and vision of family justice center organizers: San Diego figured it out. They’ve got a city attorney named Casey Gwinn who recognized that there’s a more compassionate way to help people who have been abused. And so he did something about it. He created what’s called the San Diego Family Justice Center. It’s a full-service center for domestic violence victims, where police officers and prosecutors and probation officers and civil attorneys and counselors and doctors and victims’ advocates and chaplains all come together to help somebody. The runaround is over in San Diego. There’s a central location where somebody who desperately needs help can find compassion and help. Victims can pick up food vouchers; they can get help with transportation; they can file for a temporary restraining order against their abusers; they can sign up for supervised visitation programs to keep their children safe; they can get their cell phone there. They can find help.

Bush continued: The San Diego Family Justice Center opened a year ago. It has already served thousands of victims. They tell me the story of Caitlin Effgen, who is a brave woman who lives in San Diego. It’s probably, unfortunately, a typical story I’m about to tell you. What’s atypical is that she found help in a brand new way of helping victims of domestic violence. Her boyfriend started hitting her. She tried to break up with him and he began to stalk her. She went to the authorities and got a restraining order, which, as the experts will tell you, sometimes works and some-

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times it doesn’t; in her case, the boyfriend continued to harass her. You can imagine the fear she felt. He pleaded guilty to charges, but he still stalked her. And then she discovered the center. They helped her get counseling. They got another restraining order. A victim’s advocate joined her and her dad in court. She got all the help she needed. I can imagine the relief that she must have felt when somebody who heard the call to love a neighbor did just that. The guy ended up behind bars, which is the right thing to (have happened). I congratulate the San Diego law enforcement officers. But more important, she got to remember what life was like without her misery. Those are her words, not mine. She found compassion. The funding I’ve set aside will help begin a national movement toward more of these centers. Fifteen will be funded through this initiative. When they work, there’s another 12 or 15 to fund, maybe even more. Maybe we can escalate the request. But the point is, we have found what can work.

Casey Gwinn, one of the SDFJC’s visionaries and most ardent supporters of the family justice center concept, worked tirelessly to lead a group of dedicated individuals to success that October day in 2002 when the center opened its doors. What many outside of San Diego County don’t realize is that Gwinn had testified relentlessly to city government to remove the barriers in the center’s path toward fruition. In a written testimony on March 12, 1992, Gwinn, who at the time was chairman of the San Diego Domestic Violence Council, related some of his experiences as a city attorney fighting on behalf of victims of violence. He recalled: In 1985, “Karen” walked into a hospital emergency room in San Diego and collapsed in the reception area. Nurses rushed out and determined she had been beaten by her husband. She had broken ribs, a collapsed lung, and internal bleeding. As they rushed her into surgery she was asked one question, “Do you want to press charges against your husband?” Predictably, she answered, “No.” The police were never called. Social workers had minimal involvement with her and four days later her husband drove her home from the hospital to three more years of abuse before she left the relationship for good. In 1991, “Margaret” called 911 and said she had fallen in her kitchen and injured her head and needed paramedics. Paramedics arrived within 10 minutes. These paramedics, however, were trained in domestic violence issues. They quickly suspected nonaccidental injury based on the victim’s description of the incident and the scene. They transported her to a hospital emergency room where domestic violence-trained nurses spent time talking to her about how the injury occurred. Within 20 minutes, Margaret admitted that she had not tripped but her husband had swung her by the arm into the door frame during an argument. Consistent with the hospital’s new domestic violence protocol, the police were called and came directly to the emergency room where they interviewed

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Margaret. Police officers located her husband and arrested him. Margaret’s case came to the City Attorney’s Domestic Violence Unit for prosecution. We filed misdemeanor spousal abuse charges against Margaret’s husband. Within days, Margaret became uncooperative. She refused to testify against her husband. We proceeded with the prosecution, based on the 911 tape, statements to the paramedics, statements to the nurses, medical records, photographs, and a partial admission from the defendant. He was ultimately convicted of spousal abuse and put in a one-year, 30-session treatment program for batterers. He has now been in counseling for six months and the violence in the relationship has stopped.

Gwinn continued: What happened in San Diego between 1986 and 1991 to cause the dramatic differences in these two real-life cases? The changes resulted from a coordinated effort of the San Diego City Attorney and the San Diego County Task Force on Domestic Violence. The task force has now concluded its work and a copy of the Final Report has been submitted to this panel. We still have many issues to address in San Diego but the changes, through multiagency cooperation, have been dramatic. We have implemented a comprehensive law enforcement protocol including an aggressive mandatory arrest policy on all probable cause felonies and a pro-arrest policy on all misdemeanors. We adopted a countywide medical service provider protocol for urgent care clinics and hospital emergency rooms. We coordinated a new protocol with our military community for the arrest of batterers within off-base military housing rather than releasing them to shore patrol. Finally, we adopted a comprehensive set of treatment standards for all counseling programs in San Diego County who receive courtordered batterers. The task force has now resulted in the creation of the San Diego Domestic Violence Council. The permanent council includes the district attorney, city attorney, Superior Court, Municipal Court, Public Defender, San Diego Police Department, San Diego Sheriff’s Department, Probation Department, Department of Social Services, military, San Diego Hospital Council, shelter community, and treatment providers. The council also has a committee system which includes representatives from over 40 agencies in San Diego County.

In his lobbying, Gwinn delivered a set of recommendations, some of which would eventually serve as a basis for the SDFJC, and some of which still presented solid ideas for future implementation. They include the following: •

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Creating a pilot project for postplea diversion on domestic violence cases or eliminating domestic violence diversion. Allowing municipal and superior court judges to sit for criminal, civil, and juvenile purposes when criminal prosecution is pending.

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Creating batterers’ work furlough facilities where batterers are in custody, obtaining treatment, and working to pay for it. Creating standardized reporting forms for hospitals. Creating standardized consent forms for hospitals regarding release of information to law enforcement. Giving incentives to medical insurance carriers to pay for batterers’ treatment or for support groups or counseling for victims of domestic violence, including services for particular ethnic groups. Creating a hotline within the Attorney General’s office for the handling and investigation of complaints on the handling of domestic violence incidents. Maintaining funding for domestic violence information sheets circulated by local law enforcement agencies. Expanding the hiring of bicultural, bilingual employees by city and county governments to provide more assistance to monolingual victims and clients served by the public workforce. Targeting corporate wellness programs statewide for expansion into services and awareness raising for domestic violence victims and perpetrators. Coordinate services for domestic violence and child abuse with substance abuse programs throughout the state. Allocating substance abuse treatment and prevention funds for treatment and intervention in domestic violence cases. Prohibiting “book and release” or “detention only” in domestic violence cases where probable cause exists for arrest. Mandating domestic violence training for all licensed clinical social workers, marriage and family counselors, and other psychotherapists. Restoring child abuse prevention program funding by the state of California and including domestic violence prevention in all new programming. Prohibiting juvenile court referrals for psychotherapy for victims of domestic violence unless the court finds that the victim is not amenable to a support group for battered women and that psychotherapy is appropriate. Increasing marriage license fees to fund shelter, prosecution, and advocacy programs. Expanding the mandated hours for law enforcement training on domestic violence issues.

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Providing legislation to clarify the role of school authorities in transporting children to court for testimony in domestic violence cases. Mandating juvenile court procedures and restraining order forms that provide that restraining orders issued by juvenile court judges be immediately entered into systems for recording of orders to enable domestic violence victims to have enforceable orders. Creating a statewide system for the compiling of restraining orders and access by law enforcement, prosecutors, and court personnel. Mandating domestic violence materials to be provided by all ministers or judicial officers to every couple obtaining a marriage license. Creating a pilot project for a domestic violence crisis response team to respond in cooperation with law enforcement to domestic violence scenes to provide support for victims and children and to refer for appropriate social service assistance. Mandating the creation of protocols for coordination between family court personnel and law enforcement when domestic violence situations are identified during restraining order proceedings. Creating a Standing Committee on Domestic Violence within the California District Attorneys Association. Mandating training on domestic violence for all child abuse professionals. Creating funding for treatment services to children of abused women. Calling for the development of intensive advocacy programs for abused mothers who face juvenile court, criminal court, and family court issues as well as issues of job training, employment, and child care. Calling for consequences throughout the criminal justice system for batterers who fail to complete counseling programs. Developing a strategy for extensive public education on domestic violence issues throughout society similar to child abuse awareness programs of years past. Requiring registration of domestic violence offenders. Calling on law enforcement agencies to allocate resources based on how officers spend their time, thereby allowing adequate resources for domestic violence enforcement and investigation activities. Mandating domestic violence reporting by professionals who deal with domestic violence

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similar to current reporting requirements for child abuse. Allocating a portion of lottery proceeds to address domestic violence education within the school system. Calling for parent awareness sessions within the public school system to raise the consciousness of parents to the consequences of domestic violence in the home. Allocating a percentage of alcohol taxes for community-based domestic violence treatment programs for indigent abusers and for shelter and support services for victims. Creating a working group within the California Criminal Justice Council to identify domestic violence issues and coordinate strategies for effective intervention. Calling for local sales tax initiatives to fund advocacy and intervention efforts for battered women and their children. Creating batterers’ treatment programs within the Department of Corrections to provide longterm batterers with treatment while felony abusers are incarcerated. Calling for the Department of Corrections to utilize private batterers’ programs for domestic violence offenders and parolees after release from state prison. Allocating funding for regional shelters for battered women to ensure availability throughout each county in California.

Gwinn recalls the day he got the phone call he’d anxiously been waiting for: It was September, 1989. After a phone call from City Attorney John Witt, the district attorney had agreed to listen to my proposal for a “one-stop shop” domestic violence service center in San Diego. I had written a 10page proposal to be distributed to all the supervisors in the DA’s Office. The premise was simple: Victims would have an easier time receiving needed services if they only had to go one place to get all the necessary help. I arrived in the DA’s office on the 14th floor of the Wells Fargo Building downtown and was ushered into the main conference room. The heads of each branch were present, along with the assistant district attorney and the chief deputy. My proposal was passed out and I was given the floor for 20 minutes. After the conclusion of my presentation, there were a few questions and I was ushered out. I never got a formal response to my proposal; not a week later, not a month later. It was fair to say that a one-stop shop for domestic violence victims was an idea whose time had not come. Even after that discouraging day, though, Assistant City Attorney Gael Strack and I remained determined to move forward with the concept. By the early 1990s, we had the YWCA and CCS on site

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with full-time staff. We expanded our own advocacy program with grants and city eneral fund revenue. Soon thereafter, we had staff from the district attorney’s Victim Witness Program in our unit, and our attorneys were crossdeputized to handle felonies as well as misdemeanors. As part of our determination to move forward with a limited one-stop shop, we began rotating prosecutors over to the police department on a weekly basis and had detectives coming over to our office on a weekly basis. We successfully pursued grants for partnerships with Children’s Hospital and Child Protective Services. Within a year of that humble beginning to a multidisciplinary service center it was abundantly clear that the idea was the right one. Victims could get a restraining order and see a prosecutor. They could talk to a detective and meet with an advocate from Children’s Hospital.

A turning point came in 1998, Gwinn says: Finally, David Bejarano became the police chief of San Diego. It was an answer to prayer. Within six months, he and I sat down and talked about two initiatives: creation of a Neighborhood Prosecution Unit, and creation of a one-stop shop for victims of domestic violence. The rest, as they say, is now history. With a cast of hundreds and the passion of a small core, we did it! We took our small, limited idea of co-located services and exploded it into a national model now becoming known as the San Diego Family Justice Center. And we are not done. Even as the rest of the country begins to follow our lead, we will keep moving forward to the next level. We will not stop. We will not rest on our laurels. We will not bruise each other with pats on the back. We will refuse to settle. We will continue to aspire until one day women, men, and children do not die in domestic violence homicides in San Diego. We will continue to strive until services are coordinated countywide and hurting families get the help they need in every corner of San Diego County. Nothing will be good enough until every child from a domestic violence home has the opportunity to break free from violence and discover their God-given gifts and abilities. We will build the best camping facilities in America for domestic violence victims and their children. And we will push for prevention initiatives as never before. The goal is not too ambitious. The vision is not too lofty. The San Diego Family Justice Center is, without question, an idea whose time has now come.

One of the most significant components of the SDFJC is the Forensic Medical Unit (FMU), which was the first freestanding forensic medical unit in the country at the time of its inception in 2002. The FMU is a private suite with two medical exam rooms and staff offices. It provides a safe, comfortable area for victims so that they will not be forced to wait in nonsecure public areas or busy hospital-based ED for care. The unit is staffed by a full-time forensic nurse practitioner and two half-time emergency medicine physicians who are national experts in the field

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of domestic violence injuries, George McClane, MD and Ellen Taliaferro, MD. Additional staff will be added as the unit continues to grow. “What makes the Forensic Medical Unit truly unique is that it is part of a collaborative effort involving law enforcement, forensic medicine and the City Attorney’s Office,” says McClane, who serves as the FMU’s medical director. “It is a place where victims of domestic violence, whether they are young or old, can go to be treated and where injuries can be forensically evaluated.” McClane adds that forensic medicine is a crucial element in prosecuting perpetrators of domestic violence. “The forensically-based evidence plays a major role in solving the crime,” McClane says. The FMU at the SDFJC began its operations on April 1, 2003, and saw its first patient on May 1, 2003. To date, it has provided medical care to more than 100 victims of domestic violence, including both men and women. The types of injuries handled at the FMU include contusions, abrasions, minor lacerations or sprains, as well as injuries to the head, neck, chest, breasts, abdomen, arms, and legs. Life-threatening injuries are referred to local hospital ERs. Victims have sought medical care at the FMU or have been referred by the San Diego Police Department. “In many domestic violence cases, it is essential to document the victim’s injuries as quickly as possible,” said San Diego Police Chief William Lansdowne. “The Family Justice Center’s Forensic Medical Unit provides one more opportunity to collect detailed evidence and share it with prosecutors housed at the Family Justice Center. When abusers are prosecuted and held accountable for their crimes, it is much more difficult for them to reoffend.” The FMU’s care includes documentation of external and internal injuries and follow-up documentation; preservation of physical evidence for prosecution of abusers; detection of internal injuries caused by strangulation or blunt force trauma; detection of mental health and psychiatric symptoms; intervention in cases involving pregnant women; patient and victim education and safety; continuity of care and long-term support for victims; communication and collaboration among all intervention professionals; statistical record keeping and research; and education, awareness, and outreach to hospitals and clinics about the FMU and the SDFJC. The unit also provides referrals for well-child checkups and women’s care. According to McClane, who is also a Sharp Grossmont Hospital ED physician, other similar forensic units across the country might work only with specific populations such as child abuse victims, or are located within a hospital and do not provide the comprehensive services and access to the continuum of care. “Most importantly, after they receive their medical exam, all the social services and law enforcement services they need are right there in the building,” says Assistant City Attorney Gael Strack, the on-site coordinator of the SDFLC.

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Although some professionals might be skeptical of the one-stop shop concept, there’s no denying the positive impact that these types of centers can have on the community. In its very first year of operation, the SDFJC: • • • • • • • • • • •

Assisted 5,700 victims, including 750 children. Facilitated 4,962 meetings between professionals assisting domestic violence victims. Fielded 31,578 phone calls. Had 20,665 hits on its Web site. Saw the filing of 11,368 SDPD police reports. Facilitated 4,393 cases with the City Attorney. Saw 712 trials set. Saw 70 trials conducted. Saw 3,942 cases reviewed by probation in DV Court. Cared for 131 clients in the FMU. Benefited from 5,204 volunteer hours.

Since it opened in 2002, the SDFJC has had visitors from more than 35 states and 18 countries. The number of walk-in victims of domestic violence has gone from 87 in its first month of operation to 636 walk-in victims in September 2003. City officials report that the center has been an integral part of their efforts to prevent domestic violence and assist victims. “Most importantly,” Gwinn says, “we are seeing domestic violence murders continue to decline. We have gone from 30 domestic violence homicides in the city in 1985 to nine in 2002, to four in 2003.” The SDFJC engaged in participatory strategic planning from the very beginning. This process was viewed as essential to successfully forge the multiple partnerships and complex service systems that are housed under a single roof in the SDFJC model. By working together in a strategically planned synergistic fashion, this collaborative effort has and will continue to provide victims and children involved in domestic violence with more support, improved accessibility to services and resources, and make the entire process of reporting a domestic violence incident much less overwhelming for the victims and children involved. Organizers say it will take two phases to bring the SDFJC to life fully. Phase I was implemented in October 2002 when the SDFJC became the first in the country to house an entire police department’s Domestic Violence Unit and a city’s Prosecutorial Domestic Violence Unit. During Phase I, victim injuries were evaluated, documented, and treated. Phase II is the ultimate dream, a permanent home. On October 19, 2002, the SDFJC gala kicked off a $10 million capital campaign to make this part of the dream a reality. Phase II envisions the purchase and renovation of a specialized facility that will allow the inclusion of professionals handling child abuse, elder abuse, and sexual assault cases. Phase II implementation is projected to take approximately three to five years.

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Through January 2004, the SDFJC saw an additional 1,067 victims (including 216 children), fielded 5,821 more phone calls, received 5,335 more hits on its Web site, saw 88 more trials set, treated 54 more people in the FMU, and benefited from 1,509 additional volunteer hours. By 2007, the center plans to offer comprehensive medical and legal services, counseling to victims and children; links to juvenile, family, and criminal court; as well as access to on-site professionals such as child protective service workers, probation, parole and border patrol officers, and others. The SDFJC is unique in many of its configurations and operations, as it should be, experts say. A cookie-cutter approach will not be sufficient to address numerous socioeconomic factors that affect jurisdictions and communities across the country. “There are going to be many different models that come out of the one-stop shop concept,” Diana Faugno says: It will be up to each community to determine which one is best for them. For example, the SDFJC isn’t able to help us here in North County San Diego, and I can’t use any of their services because of distance and cost. Whether the family justice center and the community are connected by the dotted lines on paper or is actually connected to the community, whatever is going to work in that specific community will be the best model or the best practice. What you are looking for is volume of victims and where is it located in the region; from there, it’s just a matter of finding the pole upon which you’re going to hang your hat.

7.10 THE FUTURE Carlson (2005) says that in the past 20 years, important insights have been gained regarding violence and trauma, how complications occur, their causes, and their effects on victims. Carlson adds that violence and abuse toward women—physical, sexual, and emotional—are not rare events and are most often perpetrated by partners or acquaintances rather than strangers. These events occur in nonmarital as well as marital relationships, including same-sex relationships. Carlson emphasizes that future research should address increased understanding of variation in individual responses to violence and trauma, matching of treatment to different types of male offenders, better understanding of how culture affects violence perpetration and victimization, and evaluation of domestic violence interventions.

REFERENCES American Psychological Association. Medical Providers Need More Training to Spot and Intervene in Cases of Domestic Violence, According to New Study. [Press release,

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August, 2000]. Available at www.apa.org/releases/domviolence.html Bachman, R., Ed. Violence Against Women: A National Crime Victimization Survey Report. Washington, DC: U.S. Department of Justice. 1994. Bair-Merritt, M. H., Giardino, A. P, Turner, M., Ganetsky, M., & Christian, C. W. Pediatric residency training on domestic violence: A national survey. Ambul Pediatr. 4, 1, 24–27, 2004. Bell, C. C., Jenkins, E. J., Kpo, W., & Rhodes, H. Response of emergency rooms to victims of interpersonal violence. Hosp Community Psychiatry. 45, 2, 142–146, 1994. Briere, J., Woo, R., McRae, B., Foltz, J., & Sitzman, R. Lifetime victimization history, demographics, and clinical status in female psychiatric emergency room patients. J Nerv Men Dis. 185, 95–101, 1997. Campbell, D. W., Sharps, P. W., Campbell, J. C., & Lopez, L. M. Intimate partner violence in African American women. Online J Issues in Nursing. 7, 1, 5, 2002. Campbell, J. C. Risk Factors for Femicide in Abusive Relationships: Results from a Multi-site Case Control Study. [Press release] Johns Hopkins University. 2003. Carlson, B. E. The most important things learned about violence and trauma in the past 20 years. J Interpers Violence. 20, 1, 119–126, 2005. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Intimate partner violence fact sheet. 2000. Available at: www.cdc.gov/ncipc/dvp /dvam.htm. Coker, A., Smith, P., Bethea, L., King, M., & McKeown, R. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med. 9, 5, 451–457, 1997. Craine, L., Henson, C., Colliver, J., & MacLean, D. Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hosp Community Psych. 39, 3, 300–304, 1988. Elliott, B. A., & Johnson, M. M. Domestic violence in a primary care setting: Patterns and prevalence. Arch Fam Med. 4, 113–119, 1995. Family Violence Prevention Fund. Catalog of training and education materials on domestic violence. Available at: http://www.fvpf.org. Family Violence Prevention Fund. Identifying and Responding to Domestic Violence: Consensus Recommendations for Child Adolescent Health. Washington, DC: U.S. Department of Justice, Office for Victims of Crime. 2002. Family Violence Prevention Fund. Improving health care response to domestic violence: A resource manual for health care providers. Available at: http://www.fvpf.org. Family Violence Prevention Fund. Improving health care response to domestic violence: A training manual for health care providers. Available at: http://www.fvpf.org. Family Violence Prevention Fund. Preventing domestic violence: Clinical guidelines on routine screening. 1999. Available at: http://www.fvpf.org. Family Violence Prevention Fund. State-by-state report card on health care laws and domestic violence. 2000. Family Violence Prevention Fund. National consensus guidelines on identifying and responding to domestic violence vic-

236

timization in health care settings. Available at: http://endabuse.org/programs/healthcare/files/consensus.pdf Freidman, L. S., Samet, J. H., Roberts, M. S., Hudlin, M., & Hans, P. Inquiry about victimization experiences: A survey of patient preferences and physician practices. Arch Intern Med. 152, 6, 1186–1190, 1992. Gin, N. E., Rucker, L., Frayne S., Cygan R., & Hubbell, F.A. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Internal Med. 6, 317–222, 1991. Golding, J. Sexual assault history and long-term physical health problems: Evidence from clinical and population epidemiology. Current Directions in Psycho Sci. 8, 191–194, 1999. Hamberger, L. K., Saunders, D. G., & Hovey, M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med. 24, 283–287, 1992. Houry, D., Sachs, C. J., Feldhaus, K. M., & Linden, J. Violenceinflicted injuries: Reporting laws in the 50 states. Ann Emerg Med. 39, 1, 56–60, 2002. Housekamp, B. M., & Foy, D. The assessment of posttraumatic stress disorder in battered women. J Interpers Violence. 6, 3, 367–375, 1991. Kilpatrick, D., Best, C. L., Veronen, L. J., Amick, A. E., Villeponteaux, L.A., & Ruff, G. A. Mental health correlates of criminal victimization: A random community survey. J Consult Clin Psycho. 53, 6, 866–873, 1985. Kilpatrick, D., Edmunds, C., & Seymour, A. Rape in America: A Report to the Nation. Charleston, SC: National Victim Center and the Crime Victims Research and Treatment Center, Medical University of South Carolina. 1992. Kimerling, R., & Calhoun, K. S. Somatic symptoms, social support, and treatment seeking among sexual assault victims. J Consult Clin Psychol. 62, 333–340, 1994. Koss, M. P., Koss, P. G., & Woodruff, W. J. Deleterious effects of criminal victimization on women’s health and medical utilization. Arch Intern Med. 151, 342–347, 1991. McFarlane, J., Malecha, A., Watson, K., Gist, J., Batten, E., Hall, I., & Smith, S. Intimate partner sexual assault against women: Frequency, health consequences, and treatment outcomes. Obstet Gynecol. 105, 1, 99–108, 2005. McGrath, M. E., Bettacchi, A., Duffy, S. J., Peipert, J. F., Becker, B. M., & Angelo, L. Violence against women: Provider barriers to intervention in emergency departments. Acad Emerg Med. 4, 4, 297–300, 1997. McLeer, S. V., & Anwar, R. A study of battered women presenting in an emergency department. Am J Public Health. 79, 65–66, 1989. Miller, T. R., Cohen, M. A., Rossman, S. B. Victim costs of violent crime and resulting injuries. Health Aff. 12, 4, 186–197, 1993. Moffitt, T., & A. Caspi. New Study Examines Scope of Partner Violence [Press release, July 14, 1999]. University of Wisconsin–Madison. Available at www.news.wisc.edu/ 353.html Moore, M. L., Zaccaro, D., & Parsons, L. H. Attitudes and practices of registered nurses toward women who have experienced abuse/domestic violence. J Obstet Gynecol Neonatal Nurs. 27, 2, 175–182, 1998.

Forensic Nursing

National Academies of Sciences. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC. 2000. New York City Department of Health, Bureau of Injury Epidemiology. Femicide in New York City: 1995–2002. www.health.state.ny.us. 2004. Nibert, D., Cooper, S., & Crossmaker, M. Assaults against residents of a psychiatric institution: Residents’ history of abuse. J Interpers Violence. 4, 3, 342–349, 1989. Parsons, L. H., & Moore, M. L. Family violence issues in obstetrics and gynecology, primary care, and nursing texts. Obstet Gynecol. 90, 4 (Pt 1), 596, 1997. Rath, G. D., Jarratt, L. G., & Leonardson, G. Rates of domestic violence against adult women by men partners. J Am Board Fam Pract. 2, 227–233, 1989. Rodriguez, M., Bauer, H., McLoughlin, E., & Grumbach, K. Screening and intervention for intimate partner abuse. JAMA. 282, 5, 468–474, 1999. Sachs, C. J., Baraff, L. J., & Peek, C. Need for law enforcement in cases of intimate partner violence in a university ED. Am J Emerg Med. 16, 1, 60–63, 1998. Sachs, C. J., Koziol-McLain, J., Glass, N., Webster, D., & Campbell, J. A population-based survey assessing support for mandatory domestic violence reporting by health care personnel. Women Health. 35, 2–3, 121–133, 2002. Sachs, C. J., Peek, C., Baraff, L. J., & Hasselblad, V. Failure of the mandatory domestic violence reporting law to increase medical facility referral to police. Ann Emerg Med. 31, 4, 488–494, 1998. Saunders, D. G., Hamberger, L. K., & Hovey, M. Indicators of woman abuse based on a chart review at a family practice center. Arch Fam Med. 2, 537–543, 1993. Sethi, D., Watts, S., Zwi, A., Watson, J., McCarthy, C. Experience of domestic violence by women attending an inner city accident and emergency department. Emerg Med J. 21, 2, 180–184. 2004. Stark, E., Flitcraft, A., & Frazier, W. Medicine and patriarchal violence: The social construction of a private event. Int J Health Serv. 9, 461–493, 1997. Stuart, P. Risk factors for recent domestic physical assault in patients presenting to the emergency department. Emerg Med Australas. 16, 3, 216–224, 2004. Surgeon General’s Workshop on Violence and Public Health: Report. Washington, DC: U.S. Department of Health and Human Services, Public Health Service. 1986. Tilden, V. P., Schmidt, T. A., Limandri, B. J., Chiodo, G. T., Garland, M. J., & Loveless, P. A. Factors that influence clinicians’ assessment and management of family violence. Am J Public Health. 84, 4, 628–633, 1994. Tjaden, P., & Thoennes, N. Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice, Centers for Disease Control, Bureau of Justice Statistics. 2000. U.S. Department of Justice. Improving the Health and Mental Health Care Systems’ Responses to Violence Against Women, Toolkit to End Violence Against Women. Washington, DC. 2001.

Interpersonal Violence

Washington State Department of Health. Women’s Childhood Abuse Liked to Later Poor Health. [Press release, June 26, 2003]. Available at www.hbns.org. Woodtli, M. B., & Breslin, E. Violence-related content in the nursing curriculum: A national study. J Nurs Educ. 35, 8, 367–374, 1996. Woodtli, M., & Breslin, E. Violence-related content in the nursing curriculum: A follow-up national survey. J Nurs Educ. 41, 8, 340–348, 2002. Zawitz, M. W., Ed. Violence Between Intimates. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. 1994.

RECOMMENDED READINGS Abbott, J., Johnson, R., Koziol-McLain, J., Lowenstein, S. R. Domestic violence against women incidence and prevalence in an emergency department population. JAMA. 273, 1763–1767, 1995. Adams, D. Guidelines for doctors on identifying and helping in their patients who batter. J M Women’s Association. 51, 123–126, 1996. Alpert, E. T., Seeherman, A., & Holtz, H. Family violence curricula in U.S. medical schools. Am J Prevent Med. 14, 4, 273–282, 1998. American Academy of Pediatrics. The role of the pediatrician in recognizing and intervening on behalf of abused women. Am Acad Pediatr. Jun, 101, 6, 1–5, 1998. American Academy of Pediatrics Task Force on Adolescent Assault Victim Needs. Adolescent assault victim needs: A review of issues and model protocol. Pediatrics. 98, 5, 991–1001, 1996. American Association of Colleges of Nursing. Violence as a Public Health Problem. Washington, DC: American Association of Colleges of Nursing. 1999. American Association of Health Plans/Commonwealth Fund. Best Practices in Women’s Health: Identifying Exemplary Care: Domestic Violence. Washington, DC: American Association of Health Plans. 1999. American Association of Health Plans/Commonwealth Fund. Advancing Women’s Health: Health Plan Innovative Programs in Domestic Violence. Washington, DC: American Association of Health Plans. 1998. American College of Emergency Physicians. List of key elements of family violence protocols. Emergency Medicine Practice Committee Subcommittee on Key Elements of Domestic Violence Protocols. Available at: http://www.acep.org. American College of Obstetricians and Gynecologists. Domestic violence: The role of the physician in identification, intervention, and prevention: A slide lecture presentation. Washington, DC: American College of Obstetricians and Gynecologists. 1995. American College of Obstetricians and Gynecologists. Intimate Partner Violence During Pregnancy: A Guide for Clinicians. Washington, DC: American College of Obstetricians and Gynecologists. 2000. American College of Physicians/American Society of Internal Medicine. Medical Knowledge Self-Assessment Pro-

237

gram: MKSAP 12—Ambulatory Medicine. Chicago: American College of Physicians/American Society of Internal Medicine. 2001. American Medical Association. Diagnostic and Treatment Guidelines on Domestic Violence. Chicago: American Medical Association. 1992. American Medical Association. Prevention of Violence and Abuse Resolution (419). 2000. Available at: http://www .ama-assn.org. American Osteopathic Association. Domestic, family and school violence education. Adopted by the House of Delegates of the American Osteopathic Association (originally in 1991; revised 1996, 2001). American Osteopathic Association. Violence—Development of programs to reduce. Adopted by the House of Delegates of the American Osteopathic Association (originally in 1991; revised 1996, 2001). American Physical Therapy Association. Excerpts from American Physical Therapy Association’s guidelines for recognizing and providing care for victims of domestic abuse. Phys Ther. 6, 10, 81–82, 84, 1998. Anderson, D., Harris, M., & McCosker, H. Violence against women: An education program for rural community health workers. Aust J Rural Health. 5, 1, 17–21, 1997. Bergman, B., & Brismar, B. A five-year follow-up study of 117 battered women. Am J Public Health. 81, 11, 1486–1489, 1991. Brannen, S. J., Bradshaw, R. D., Hamlin, E. R., Fogarty, J. P., Colligan, T. W. Spouse abuse: Physician guidelines to identification, diagnosis, and management in the uniformed services. Mil Med. 164, 1, 30–36, 1999. Bullock, K. Domestic violence training at an inner-city hospital found helpful. J Emerg Nurs. 23, 4, 299–300, 1997. Bureau of Justice Statistics. Special Report: Intimate Partner Violence and Age of Victim, 1993–99. Washington, DC: U.S. Department of Justice. 2001. California Medical Training Center. Advanced training in domestic violence for health care providers. Training Course and Manual. Available at: http://web.ucdmc .ucdavis.edu/medtrng/training/events.html. California Medical Training Center. Forensic examination for victims of domestic violence. Available at: http://web .ucdmc.ucdavis.edu/medtrng/training/events.html. California Medical Training Center. Improving the health care response to violence. 1999. Available at: http://web .ucdmc.ucdavis.edu/medtrng/training/events.html. Callaghan, J. Elder abuse and one community’s response. Int J Health Care Quality Assurance Inc Leadersh Health Serv. 11, 2–3, vi–xi, 1998. Capezuti, E., & Siegler, E. L. Educating health and social service professionals in the detection and management of mistreated nursing home residents. J Elder Abuse Negl. 8, 3, 73–86, 1996. Caralis, P., & Musialowski, R. Women’s experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims. South Med J. 90, 1075–1080, 1997. Chamberlain, L. P., & Perham-Hester, K. A. Physicians’ screening practices for female partner abuse during prenatal visits. Matern Child Health J. 4, 2, 141–148, 2000.

238

Chez, R. H., & Horan, D. L. Response of obstetrics and gynecology program directors to a domestic violence lecture module. Am J Obstetr Gynecol. 180, 2 (Pt 1), 496–498, 1999. Clark, C., Becker, M., Giard, J., Mazelis, R., Savage, A., & Vogel, W. The role of coercion in the treatment of women with co-occurring disorders and histories of abuse. J Behav Health Serv Res. 32, 2, 167–181, 2005. Clarke, M. E., & Pierson, W. Management of elder abuse in the emergency department. Emerg Med Clin North Am. 17, 3, 631–644, 1999. Cohall, A., Cohall, R., Bannister, H., & Northridge, M. Love shouldn’t hurt: Strategies for health care providers to address adolescent dating violence. J Am Med Women’s Association. 54, 3, 144–148, 1999. Coker, A., Smith, P., Bethea, L., King, M., & McKeown, R. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med. 9, 5, 451–457, 2000. Cole, T. B. Is domestic violence screening helpful? JAMA. 284, 5, 551–553, 2000. Coonrod, D. V., Bay, R. C., Rowley, B. D., Del Mar, N. B., Gabriele, L., Tessman, T. D., & Chambliss, L. R. A randomized controlled study of brief interventions to teach residents about domestic violence. Acad Med. 75, 1, 55–57, 2000. Cowley, S., Rush, J., Lenton, L., & Lukasik-Foss, L. Care of the abused woman: A hospital’s educational program assesses values and beliefs. Health Progress. 77, 2, 26–29, 1996. Culross, P. L. Healthcare system responses to children exposed to domestic violence. Future Child. 9, 3, 111–121, 1999. Currier, G. W., Barthaeur, L. M., Begier, E., & Bruce, M. L. Training and experience of psychiatric residents in identifying domestic violence. Psychiatr Serv. 47, 5, 529–530, 1996. Davenport, S. Domestic violence policy and procedure: Carondelet Health Network. Tucson, AZ: St. Mary’s Hospital. 1996. Dearwater, S. R., Coben, J. H., Campbell, J. C., Nah, G., Glass, N., McLoughlin, E., & Bekemeier, B. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA. 280, 433–438, 1998. DeLahunta, E. T. Resistance to adding curricula about domestic violence. Acad Med. 73, 7, 726–727, 1998. Dienemann, J., Trautman, D., Shahan, J., Pinnella, K., Krishnan, P., Whyne, D., Bekemeier, B., & Campbell, J. Developing a domestic violence program in an inner city academic health center emergency department: The first three years. J Emerg Nurs. 25, 2, 110–115, 1999. Edleson, J. L. Children’s witnessing of adult domestic violence. J Interpers Violence. 14, 8, 839–870, 1999. Edleson, J. L. The overlap between child maltreatment and woman battering. Violence Against Women. 5, 2, 134–154, 1999. Eisenstat, S. A., & Bancroft, L. Domestic violence. N Engl J Med. 341, 12, 886–892, 1999.

Forensic Nursing

Emergency Nurses Association. Domestic violence & child maltreatment: Position Statement. Available at: http://www .ena.org/services/posistate/data/tresex.htm. Family Violence Prevention Fund. Preventing Domestic Violence: Clinical Guidelines on Routine Screening. San Francisco: Family Violence Prevention Fund. 1999. Fanslow, J. L., Norton, R. N., & Robinson, E. M. One-year follow-up of an emergency department protocol for abused women. Aust N Z J Public Health. 23, 4, 418–421, 1999. Fanslow, J. L., Norton, R., Robinson, E. M., & Spinola, C. G. Outcome evaluation of an emergency department protocol of care on partner abuse. Aust N Z J Public Health. 22, 5, 598–603, 1998. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Kiss, M. P., & Marks, J. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prevent Med. 14, 4, 245–258, 1998. Flitcraft, A. Project SAFE: Domestic violence education for practicing physicians. Women’s Health Issues. 5, 4, 183–188, 1995. Freeman, J. Old law, new bite mandatory abuse training. J Iowa Med Soc. 90, 15, 15, 2000. Friedman, L., Samet, J., Roberts, M., Hudlin, M., & Hans, P. Inquiry about victimization experiences: A survey of patient preferences and physician practices. Arch Internal Med. 152, 1186–1190, 1992. Frieze, I. R. Investigating the causes and consequences of marital rape. J Women Culture Soc. 8, 532–553, 1983. Gantt, L., & Bickford, A. Screening for domestic violence: How one hospital network started asking about abuse. AWHONN Lifelines. 3, 2, 36–42, 1999. Gelles, R. J., & Harrop, J. W. Violence, battering, and psychological distress among women. J Interpers Violence. 4, 1, 400–420, 1989. Gerbert, B. M., Caspers, N., Bronstone, A., Moe, J., & Abercrombie, P. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med. 131, 8, 578–584, 1999. Gerbert, B. M., Moe, J., Caspers, N., Salber, P., Feldman, M., Herzig, K., & Bronstone, A. Simplifying physicians’ response to domestic violence. West J Med. 172, 329–331, 2000. Glass, N., & Campbell, J. C. Mandatory reporting of intimate partner violence by health care professionals: A policy review. Nurs Outlook. 46, 6, 279–283, 1998. Haack, D. Suggested Protocols for Victims of Spousal and Elder Abuse: A Task Force Reference Document for Colorado Hospitals. Denver: Colorado Department of Health. 1996. Haase, C. S., Short, P. D., Chapman, D. M., & Dersch, S.A. Domestic violence education in medical school: Does it make a difference? Acad Emerg Med. 6, 8, 855–857, 1999. Hadley, S. M. Documentation in the medical record of potential cases of domestic violence. In WomanKind Policies and Procedures (pp. 1–7). Minneapolis, MN: Fairview Health Services. 1995.

Interpersonal Violence

Hadley, S. S., Lezin, N., & Zook, E. An innovative model of health care response to domestic abuse. Women’s Health Issues. 5, 4, 189–198, 1995. Hamberger, L. K., Ambuel, B., Marbella, A., & Donze, J. Physician interaction with battered women: The women’s perspective. Arch Fam Med. 7, 575–582, 1998. Harwell, T. S., Casten, R. J., Armstrong, K. A., Dempsey, S., Coons, H. L., & Davis, M. Results of a domestic violence training program offered to the staff of urban community health centers. Am J Prevent Med. 15, 3, 235–242, 1998. Hawkins, J. W. Intimate partner violence: A death sentance for women. Clinical Excellence for Nurse Practitioners, 6, 3, 2002. Hill, J. R. Teaching about family violence: A proposed model curriculum. Teach Learn Med. 17, 2, 169–178, 2005. Horan, D. L., Chapin, J., Klein, L., Schmidt, L.A., & Schulkin, J. Domestic violence screening practices of obstetricians and gynecologists. Obstet Gynecol. 92, 5, 785–789, 1998. Hotch, D., Grunfeld, A., Mackay, K., et al. Improving your health care facility’s response to domestic violence: Objectives and expectations. In Domestic Violence Intervention by Emergency Department Staff (pp. 1–4). Vancouver, BC: Vancouver Hospital and Health Sciences Centre. 1995. Hotch, D., Grunfeld, A., Mackay, K., & Ritch L. Policy and procedures for domestic violence patients in Canadian emergency departments: A national survey. J Emerg Nurs. 22, 4, 278–282, 1996. Hoyt, C. A. Evidence recognition and collection in the clinical setting. Crit Care Nurs Q. 22, 1, 19–26, 1999. Jonassen, J. A., Pugnaire, M. P., Mazor, K., Regan, M. B., Jacobson, E. W., Gammon, W., Doepel, D. G., & Cohen, A. J. The effect of a domestic violence interclerkship on the knowledge, attitudes, and skills of third-year medical students. Acad Med. 74, 7, 821–828, 1999. Kilpatrick, D. G. What is violence against women: Defining and measuring the problem. J Interpers Violence. 19, 11, 1209–1234, 2004. Kilpatrick, D. G., Edmunds, C. N., & Seymour, A. K. Rape in America: A report to the nation. Arlington, VA: National Victim Center and Medical University of South Carolina. 1992. Kilpatrick, K. I., Litt, M., & Williams, L. Post-traumatic stress disorder in child witnesses to domestic violence. Am J Orthopsychiatry. 67, 4, 639–644, 1997. Kingston, P., Penhale, B., & Bennett, G. Is elder abuse on the curriculum? The relative contribution of child abuse, domestic violence and elder abuse in social work, nursing and medicine qualifying curricula. Health Soc Care Community. 3, 6, 353–362, 1995. Knight, R. A., & Remington, P. L. Training internal medicine residents to screen for domestic violence. J Womens Health Gend Based Med. 9, 2, 167–174, 2000. Konchak, P. S. Domestic violence: A primer for the primary care physician. J Am Osteopath Assoc. 98, 12, S11–S14, 1998. Koss, M. P., Dinero, T. E., Seibel, C. A., & Cox, S. L. Stranger and acquaintance rape: Are there differences in the victim’s experience. Psychol Women Q. 12, 1–24, 1988.

239

Koss, M. P., & Heslet, L. Somatic consequences of violence against women. Arch Fam Med. 1, 53–59, 1992. Koziol-McLain, J., Coates, C., & Lowenstein, S. Predictive validity of a screen for partner violence against women. Am J Prevent Med. 21, 2, 93–100, 2001. Kripke, E., Steele, G., O’Brien, M. K., & Novack, D. H. Domestic violence training program for residents. J Genl Intern Med. 13, 12, 839–841, 1998. Krueger, P. M., & Schafer, S. Physician awareness of domestic violence: Does continuing medical education have an impact? J Am Osteopath Assoc. 100, 3, 145–148, 2000. Lanzilotti, S. S., Jones, P., Dai, J., & Bentzien, V. EMS and the domestic violence patient: A report card of existing policy, protocol & training. J Emerg Med Serv. 24, 6, 58–66, 1999. Larkin, G. L., Rolniak, S., Hyman, K. B., MacLeod, B. A., & Savage, R. Effect of an administrative intervention on rates of screening for domestic violence in an urban emergency department. Am J Public Health. 90, 9, 1444–1448, 2000. Lawrence, L. L., & Brannen, S. J. The impact of physician training on child maltreatment reporting: A multi-specialty study. Mil Med. 165, 8, 607–611, 2000. Limandri, B. J., & Tilden, V. P. Nurses’ reasoning in the assessment of family violence. Image J Nurs Sch. 28, 3, 247–252, 1996. Limbos, M. P., & Berkowitz, C. D. Documentation of child physical abuse: How far have we come? Pediatrics. 102, 1, 53–58, 1998. Lo Vecchio, F., Bhatia, A., & Sciallo, D. Screening for domestic violence in the emergency department. Eur J Emerg Med. 5, 4, 441–444, 1998. Lucas D’Olivera, A. F., Diniz, S. G., & Schraiber, L. B. Violence against women in health care institutions: An emerging problem. Lancet. 359, 1681, 2002. MacMillan, H. L., MacMillan, J., & Offord, D. R. Primary Prevention of Child Maltreatment. Canadian Task Force on Preventive Health Care. Ottawa, Ontario, Canada: Canadian Medical Association. 1993. Markin, D. A. Fighting the silent epidemic: Hospital launches comprehensive program against domestic violence. Health Prog. 77, 2, 30–33, 1996. Martin, S., Rodriguez, M., Lee, D., & Heilig, S. San Francisco Domestic Violence Healthcare Protocol. San Francisco: San Francisco Family Violence Council’s Health Care Committee. 1997. McCauley, J., Kern, D. E., Kolodner, K., Dill, L., Schroeder, A. F., DeChant, H. K., Ryden, J., Bass, E. B., & Derogatis, L. R. The battering syndrome: Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Internal Med. 123, 737–746, 1995. McCauley, J., Yurk, R., Jenckes, M., & Ford, D. Inside Pandora’s box: Abused women’s experiences with clinicians and health services. Arch Internal Med. 13, 549–555, 1998. McFarlane, J., Christoffel, K., Bateman, L., Miller, V., & Bullock, L. Assessing for abuse: Self-report vs. nurse interview. Public Health Nurs. 8, 242–250, 1991. McFarlane, J., Greenberg, L., Weltge, A., & Watson, M. Identification of abuse in emergency departments: Effective-

240

ness of a two-question screening tool. J Emerg Nurs. 21, 391–394, 1995. McGrath, M. E., Hogan, J. W., & Peipert, J. F. A prevalence survey of abuse and screening for abuse in urgent care patients. Obstet Gynecol. 91, 4, 511–514, 1998. Moore, M. L., Zaccaro, D., & Parsons, L. H. Attitudes and practices of registered nurses toward women who have experienced abuse/domestic violence. J Obstet Gynecol Neonatal Nurs. 27, 2, 175–182, 1998. Morrison, L. J., Allan, R., & Grunfeld, A. Improving the emergency department detection rate of domestic violence using direct questioning. J Emerg Med. 19, 2, 117–124, 2000. Mouden, L. D. The role for dental professionals in preventing child abuse and neglect. J Calif Dent Assoc. 26, 10, 737–739, 741–743, 1998. Muelleman, R. A., Lenaghan, P. A., & Pakieser, R. A. Battered women: Injury locations and types. Ann Emerg Med. 28, 486–492, 1996. Myers, J. L. Workshop effectiveness: Nurses as witnesses in court cases involving physical child abuse. J Nurs Law. 3, 2, 35–44, 1996. National Institute of Justice and Centers for Disease Control and Prevention. Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice and Centers for Disease Control and Prevention. 1998. Olson, L., Anctil, C., Fullerton, L., Brillman, J., Arbuckle, J., & Sklar, D. Increasing emergency physician recognition of domestic violence. Ann Emerg. 27, 6, 741–746, 1996. Oriel, K. A., & Fleming, M. F. Screening men for partner violence in a primary care setting. J Fam Pract. 46, 6, 493–498, 1998. Osatlin, A., & Short, L. M. Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Healthcare Providers. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Protection and Control. 1998. Payne, M. R. Self-study modules help health care professionals recognize and prevent abuse. NLN Update. 2, 4, 7, 1996. Plichta, S. B. Intimate partner violence and physical health consequences: Policy and practice implications. J Interpers Violence. 19, 11, 1296–1323, 2004. Rennison, M. Intimate Partner Violence and Age of Victim, 1993–1999: Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice. Publication NCJ 187635. 2001. Rhatigan, D. L., Moore, T. M., & Street, A. E. Reflections on partner violence: 20 years of research and beyond. J Interpers Violence. 20, 1, 82–88, 2005. Roberts, G. L., Raphael, B., Lawrence, J. M., O’Toole, B., & O’Brien, D. Impact of an education program about domestic violence on nurses and doctors in an Australian emergency department. J Emerg Nurs. 23, 3, 220–227, 1997. Rodriguez, M. A., Bauer, H. M., McLoughlin, E., & Grumbach, K. Screening and intervention for intimate partner abuse: Practices and attitudes of primary care physicians. JAMA. 282, 5, 468–474, 1999.

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Rodriguez, M. A., Craig, A. M., Mooney, D., & Bauer, H. M. Patient attitudes about mandatory reporting of domestic violence: Implications for health care professionals. West J Med. 169, 6, 337–341, 1998. Rodriguez, M., Quiroga, S. S., & Bauer, H. Breaking the silence: Battered women’s perspectives on medical care. Arch Fam Med. 5, 153–158, 1996. Ross, M. M., Hoff, L. A., & Coutu-Wakulczyk, G. Nursing curricula and violence issues. J Nurs Educ. 37, 2, 53–60, 1998. Rovi, S., & Mouton, C. P. Domestic violence education in family practice residencies. Fam Med. 31, 6, 398–403, 1999. Rupp, R. P. Conditions to be considered in the differential diagnosis of child abuse and neglect. Gen Dent. 46, 1, 96–100, 1998. Sadler, D. W. The value of a thorough protocol in the investigation of sudden infant deaths. J Clin Pathol. 51, 9, 689–694, 1998. Salber, P. R., & Taliaferro, E. The Physician’s Guide to Domestic Violence: How to Ask the Right Questions and Recognize Abuse . . . Another Way to Save a Life. Volcano, CA: Volcano Press. 1995. Saltzman, L. E., Salmi, L. R., Branche, C. M., & Bolen, J. C. Public health screening for intimate violence. Violence Against Women. 3, 319–331, 1997. Saywitz, K., & Camparo, L. Interviewing child witnesses: A developmental perspective. Child Abuse Negl. 22, 8, 825–843, 1998. Schroeder, M., & Weber, J. R. Promoting domestic violence education for nurses. Nurs Forum. 33, 4, 13–21, 1998. Schwartz, I. L. Sexual violence against women: Prevalence, consequences, societal factors, and prevention. Am J Prev Med. 7, 363–371, 1991. Schwartz, M. D. The past and the future of violence against women. J Interpers Violence. 20, 1, 7–11, 2005. Sheridan, D. Forensic documentation of battered pregnant women. J Nurse Midwifery. 41, 6, 467–472, 1996. Sherin, K. M., Sinacore, J. M., & Li, X. O. A short domestic violence screening tool for use in a family practice setting. Fam Med. 30, 7, 508–512, 1998. Shields, G., Baer, J., Leininger, K., Marlow, J., & DeKeyser, P. Interdisciplinary health care and female victims of domestic violence. Soc Work Health Care. 27, 2, 27–48, 1998. Short, L. M., Johnson, D., & Osattin, A. Recommended components of health care provider training programs on intimate partner violence. Am J Prevent Med. 14, 4, 283–288, 1998. Sinai, S. H., & Stewart, C. D. Physical abuse of children: A review for orthopedic surgeons. J South Orthop Assoc. 7, 4, 264–276, 1998. Smock, W. S., Nicholas, G. R., & Fuller, P. M. Development and implementation of the first clinical forensic medicine training program. J Forensic Sci. 38, 4, 835–839, 1993. Spinola, C., Stewart, L., Fanslow, J., & Norton, R. Developing and implementing an intervention: Evaluation of an emergency department pilot on partner abuse. Eval Health Prof. 21, 1, 91–119, 1998.

Interpersonal Violence

Spivak, H. The role of the pediatrician in youth violence prevention in clinical practice and at the community level. Pediatrics. 103, 5 (Pt. 1), 1080–1081, 1999. Stobo, J. D., Salmon, M. E., & Cohn, F, Eds. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: National Academy Press. 2002. Taylor, W., Sheridan, D., Campbell, J. C., et al. Battered Women: Identification, Treatment, and Referral of Nursing Network on Violence Against Women International. 1994. Thompson, R. S., Meyer, B. A., & Smith-DiJulio, K., Caplow, M. P., Maiuro, R. D., Thompson, D. C., Sugg, N. K., & Rivara, F. P. A training program to improve domestic violence identification and management in primary care: Preliminary results. Violence Vict. 13, 4, 395–410, 1998. Thurston, W. E., & McLeod, L. Teaching second-year medical students about wife battering. Womens Health Issues. 7, 2, 92–98, 1997. Tjaden, P. T. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. Washington, DC: U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. 2000. Trezona, P., Zink, T., Schlossberg, L., et al. Healthcare guideline: Domestic violence. Bloomington, IN: ICSI. 1996. U.S. Department of Health and Human Services. Child Maltreatment 1999: Reports from the States to the National Child Abuse and Neglect Data System (NCANDS). Washington, DC: U.S. Government Printing Office. 2001. U.S. Department of Justice. Violence by Intimates: Analysis of Data on Crimes by Current or Former Spouses, Boyfriends, and Girlfriends. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. 1998. U.S. Department of Justice. Intimate Partner Violence. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. 2000. Varvaro, F. F. Violence against women: The role of orthopedic nurses in the identification, assessment, treatment, and care for the abused women. Orthop Nurs. 17, 2, 33–40, 1998. Varvaro, F. F., & Gesmond, S. ED physician house staff response to training on domestic violence. J Emerg Nurs. 23, 1, 17–22, 1997.

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Vivio, D. Comments to the committee on training needs of health professionals to respond to family violence. Silver Spring, MD: American College of Nurse Midwives. 1–3, 2000. Waller, A. E., Hohenhaus, S. M., Shah, P. J., & Stern, E. A. Development and validation of an emergency department screening and referral protocol for victims of domestic violence. Ann Emerg Med. 27, 6, 754–760, 1996. Warshaw, C. Minimal elements of a domestic violence protocol. Harrisburg, PA: Family Violence Prevention Fund. 1995. Warshaw, C. Intimate partner abuse: Developing a framework for change in medical education. Acad Med. 72, 1, S26–S37, 1997. Weiss, S. J., Ernst, A. A., Blanton, D., Sewell, D., & Nick, T. G. EMT domestic violence knowledge and the results of an educational intervention. Am J Emerg Med. 18, 2, 168–171, 2000. Weiss, S., Garza, A., Casaletto, J., Stratton, M., Ernst, A., Blanton, D., & Nick, T. G. The out-of-hospital use of a domestic violence screen for assessing patient risk. Prehosp Emerg Care. 4, 1, 24–27, 2000. Welbury, R. R., & Murphy, J. M. The dental practitioner’s role in protecting children from abuse: Reporting and subsequent management of abuse. Br Dent J. 184, 3, 115–119, 1998. Whittaker, D. K., Aitken, M., Burfitt, E., & Sibert, J. R. Assessing bite marks in children: Working with a forensic dentist. Ambul Child Health. 3, 3, 225–229, 1997. Wiist, W. H., & McFarlane, J. The effectiveness of an abuse assessment protocol in public health prenatal clinics. Am J Public Health. 89, 8, 1217–1221, 1999. Wingfield, D. A., & Blocker, S. L. Development of a certificate training curriculum for domestic violence counseling. J Addiction Offender Counsel. 18, 2, 86–94, 1998. Wisehart, B. Pilot project offers help to victims of domestic violence. California Hospitals. 9, 4, 24–25, 1995. Woodtli, M. A. Domestic violence and the nursing curriculum: Tuning in and tuning up. J Nurs Educ. 39, 4, 173–82, 2000. Yexley, M., Borowsky, I., & Ireland, M. Correlation between different experiences of intrafamilial physical violence and violent adolescent behavior. J Interpers Violence. 17, 7, 707–720, 2002.

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8 Vulnerable Populations CONTENTS 8.1

8.2 8.3

8.4

8.5

Violence Against Disabled Individuals ................................................................................................................. 245 8.1.1 A Portrait of Individuals With Disabilities ............................................................................................... 245 8.1.2 Victimization of Disabled Individuals ...................................................................................................... 247 8.1.3 A Meeting of the Minds............................................................................................................................ 248 8.1.4 Underreporting Among Disabled Victims and Interface With the Criminal Justice System................... 251 8.1.5 Women With Disabilities and Sexual Violence ........................................................................................ 253 8.1.6 Children With Disabilities and Violence................................................................................................... 253 Violence Against Men ........................................................................................................................................... 254 8.2.1 Male Victims of Sexual Assault: A Review of the Literature .................................................................. 256 Violence Against LGTB Individuals ..................................................................................................................... 257 8.3.1 Murders and Domestic-Violence-Related Deaths in LGTB Communities .............................................. 258 8.3.1.1 Gender of LGTB Victims ......................................................................................................... 259 8.3.1.2 Sexual Orientation of LGTB Victims....................................................................................... 259 8.3.1.3 Ages of LGTB Victims............................................................................................................. 259 8.3.1.4 Race and Ethnicity of LGTB Victims ...................................................................................... 260 8.3.2 The Health Care Provider’s Response to LGTB Victims......................................................................... 260 Violence Against Elders ........................................................................................................................................ 261 8.4.1 Importance of Ending Ageism Increases as Life Expectancy Lengthens ................................................ 261 8.4.2 Painting a Picture of Violence Against Elders.......................................................................................... 261 8.4.2.1 Prevalence and Incidence of Elder Abuse................................................................................ 263 8.4.2.2 Elders: Protected by the Law? ................................................................................................. 264 8.4.3 Elder Abuse: A Review of the Literature.................................................................................................. 265 8.4.4 Aging: A Women’s Issue........................................................................................................................... 270 8.4.5 The 1998 Report on Elder Abuse That Shocked a Nation....................................................................... 272 8.4.6 Detection and Management of Elder Abuse in the Clinical Setting ........................................................ 274 8.4.6.1 Red Flags for Abuse ................................................................................................................. 276 8.4.6.2 Clinical and Medical Forensics of Elder Abuse ...................................................................... 276 8.4.6.3 Screening for Elder Abuse in the Clinical Setting................................................................... 278 8.4.6.4 The Patient History and Physical Examination ....................................................................... 279 8.4.6.5 Screening Tools for Elder Abuse.............................................................................................. 280 8.4.6.6 Special Considerations for Postmortem Analysis .................................................................... 280 8.4.7 Elder Abuse in the Home Setting ............................................................................................................. 280 8.4.8 Institutional Abuse and Neglect ................................................................................................................ 282 8.4.8.1 The New Nursing Home Challenge: Resident-on-Resident Violence..................................... 285 8.4.8.2 Underreporting of Elder Abuse ................................................................................................ 286 8.4.9 The Public Health Response to Elder Abuse . . . or Lack Thereof............................................................ 287 Violence Against Children..................................................................................................................................... 288 8.5.1 The Scope of the Problem......................................................................................................................... 288 8.5.2 What Is Child Abuse and Neglect?........................................................................................................... 289 8.5.3 Signs and Symptoms of Child Abuse and Neglect................................................................................... 290 8.5.3.1 Recognizing Child Abuse ......................................................................................................... 290 8.5.3.2 Types of Abuse ......................................................................................................................... 290 8.5.3.3 Munchausen Syndrome by Proxy ............................................................................................ 295 8.5.3.4 Child Abuse Versus SIDS ......................................................................................................... 298 8.5.3.5 Shaken Baby Syndrome ........................................................................................................... 299 243

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8.5.4

8.5.5

8.5.6 8.5.7

8.5.8

8.5.9

8.5.10

8.5.11

8.5.12

8.5.13 8.5.14

Other Clinical Considerations Related to Child Abuse and Neglect: A Brief Review of the Literature ............................................................................................................... 299 8.5.4.1 Intentional Burns and Scalds.................................................................................................... 299 8.5.4.2 Bruises....................................................................................................................................... 300 8.5.4.3 Head Injury ............................................................................................................................... 300 8.5.4.4 Fractures.................................................................................................................................... 301 8.5.4.5 Criterion for Diagnosing Child Abuse Based on Faulty Evidence ......................................... 301 Risk and Protective Factors for Child Abuse and Neglect ....................................................................... 302 8.5.5.1 Protective Factors...................................................................................................................... 303 8.5.5.2 Child Risk Factors .................................................................................................................... 303 8.5.5.3 Parental and Family Risk Factors ............................................................................................ 303 8.5.5.4 Social and Environmental Risk Factors ................................................................................... 303 8.5.5.5 Child Protective Factors ........................................................................................................... 304 8.5.5.6 Parental and Family Protective Factors.................................................................................... 304 8.5.5.7 Social and Environmental Protective Factors .......................................................................... 304 Mandatory Reporting of Child Abuse....................................................................................................... 304 Two Important National Reports on Child Abuse and Neglect................................................................ 305 8.5.7.1 The 1996 National Incidence Study......................................................................................... 305 8.5.7.2 National Child Maltreatment Findings From 2002 ................................................................. 314 Sexual Assault of Children........................................................................................................................ 315 8.5.8.1 Age of Sexual Assault Victims................................................................................................. 315 8.5.8.2 Gender of Sexual Assault Victims............................................................................................ 316 8.5.8.3 Other Offenses in Sexual Assault Incidents............................................................................. 316 8.5.8.4 Other Victims in Sexual Assault Incidents............................................................................... 317 8.5.8.5 Location of Sexual Assault....................................................................................................... 317 8.5.8.6 Weapons Used in Sexual Assault ............................................................................................. 318 8.5.8.7 Time of Day of the Sexual Assault .......................................................................................... 318 8.5.8.8 Gender and Age of Offenders in Sexual Assault ..................................................................... 318 8.5.8.9 Victim–Offender Relationships in Sexual Assault ................................................................... 319 8.5.8.10 Offender Profiling ..................................................................................................................... 319 8.5.8.11 Probability of Arrest and Clearance ......................................................................................... 319 A Decline in Child Sexual Abuse Cases?................................................................................................. 320 8.5.9.1 Evidence for the Decline .......................................................................................................... 321 8.5.9.2 Explanations for the Decline .................................................................................................... 321 8.5.9.3 A Real Decline in the Incidence of Sexual Abuse?................................................................. 322 8.5.9.4 A Greater Decline in the Most Readily Preventable Cases..................................................... 323 8.5.9.5 Increase in the Incarceration of Offenders............................................................................... 323 Child Sexual Assault Guidelines for Health Care Professionals.............................................................. 324 8.5.10.1 Medical Evaluation ................................................................................................................... 324 8.5.10.2 Emergency Room Examinations .............................................................................................. 325 Child Witnesses of Domestic Violence ..................................................................................................... 328 8.5.11.1 Children Who Witness Violence Are at Risk of Violence in Adulthood................................. 329 8.5.11.2 Children Whose Mothers Suffer from Abuse Are More Likely to Be Abused....................... 329 8.5.11.3 Overlap of Violence Against Women, Child Abuse, and Youth Violence ............................... 330 8.5.11.4 Effects of Physical and Sexual Violence on Children and Families ....................................... 330 Consequences of Child Abuse and Neglect .............................................................................................. 331 8.5.12.1 Factors Affecting the Consequences of Child Abuse .............................................................. 331 8.5.12.2 Physical Health Consequences ................................................................................................. 332 8.5.12.3 Psychological Consequences .................................................................................................... 332 8.5.12.4 Behavioral Consequences ......................................................................................................... 332 8.5.12.5 Societal Consequences.............................................................................................................. 333 8.5.12.6 Risk Factors for Chronic Child Maltreatment ......................................................................... 333 Presentation to the Emergency Room....................................................................................................... 333 Child Abuse: Investigation, Prosecution, and Expert Witness Testimony Issues .................................... 335 8.5.14.1 The Key to Convicting Child Molesters .................................................................................. 335

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8.5.14.2 New Strategies to Prevent Child Homicide Needed................................................................ 336 8.5.14.3 Child Abuse and Neglect Fatalities .......................................................................................... 337 8.5.14.4 Nurses’ Expert Testimony in Child Abuse Cases .................................................................... 339 8.5.15 The School Nurse: A New Opportunity for Forensic Nurses .................................................................. 341 8.5.15.1 The Role of School Nurses in Youth Violence ........................................................................ 342 8.5.15.2 School Nurses and Child Abuse............................................................................................... 343 8.5.15.3 School Nurses’ Role in Bioterrorism ....................................................................................... 347 8.5.15.4 School Nurses: A Resource Stretched Thin............................................................................. 348 References ....................................................................................................................................................................... 350 Recommended Readings ................................................................................................................................................. 356

According to the WHO (2003), although any person can be victimized, there are some individuals or groups of individuals who might be more vulnerable, and so appear to be overrepresented as victims of interpersonal violence, and of sexual violence in particular. These include the following groups: • • • • • • • • • • •

Single women and lone female heads of household. Children and young adults. Children in foster care. Physically and mentally disabled men and women. Individuals in prison or held in detention. Individuals with drug or alcohol problems. Individuals with a past history of rape or sexual abuse. Individuals involved in prostitution. Individuals in an abusive intimate or dependent relationship. Victims of war or armed-conflict situations. The homeless or impoverished.

Just as there is no typical victim, perpetrators also come from all walks of life. Many times, perpetrators are the very individuals entrusted with the health, safety, and supervision of these vulnerable populations, including teachers, health care workers, day care workers, priests, community leaders, and other authority figures. Forensic nurses must be familiar with the types of violence perpetrated against members of vulnerable populations, as well as the specific makeup of each group of patients who might present to the health care facility as victims of violence, abuse, or neglect. Barbara Moynihan, RN, APRN, PhD, assistant professor of nursing at Quinnipiac University in Connecticut, says that there are numerous opportunities for forensic nurses to work among vulnerable populations: Counted among these populations are individuals from other countries who flee oppression, and people who have been terrorized, abused, assaulted, and held hostage. Cultural sensitivity is so important, whether a forensic nurse

is dealing with someone from a different race or culture. Everyone does not think, feel, or act the same way, even though they may look the same. Migrant populations, illegal immigrants, and others who are in minority populations have health care needs that are largely ignored by the system. Look at the returning military personnel who have been traumatized and suffer from posttraumatic stress disorder. They are dealing with horrendous injuries and mental trauma as they attempt to integrate back into society. So there are many challenges and opportunities within these kinds of underserved populations with which forensic nurses may become involved.

Moynihan says that medico-legal issues such as elder abuse are starting to gain increasing awareness. “There is much more information about elder abuse today than ever before; it’s coming out of the closet; and the unspeakable is being spoken. We’re broadening our scope of assessment to identify these kinds of forensic clients.”

8.1 VIOLENCE AGAINST DISABLED INDIVIDUALS 8.1.1 A PORTRAIT DISABILITIES

OF INDIVIDUALS

WITH

The most widely accepted estimate of the number of people with disabilities is 49 million noninstitutionalized Americans (McNeil, 1993). As such, people with disabilities constitute the single largest minority group identified in the United States, surpassing the elderly (about 33.2 million) and African Americans (about 32.7 million), according to the U.S. Bureau of the Census in 1995. An October 1997 update to this report indicates 54 million Americans report having some level of disability, with 26 million of those having a severe disability. The percentage of people with a disability increases with age. Whereas 5 percent of the population younger than age 18 has a disability, 84.2 percent of those age 85 and over have a disability. Of those between 18 and 44, 13.6 percent have a disability, and of those between 45 and 64, 29.2 percent have a disability. Males had a disability rate of 18.7 percent and a severe disability rate of 8.1 percent. For females, the corresponding rates were 20.2 percent and

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11 percent. These Americans live with a wide array of physical, cognitive, and emotional disabilities. Some disabilities are more easily discernable than others. People who use wheelchairs, service animals, or walkers are easy to identify. Less obvious are those with intellectual or mental disabilities (such as people who have learning disabilities or schizophrenia) and those with chronic illnesses (such as chronic fatigue syndrome, seizure disorders, arthritis, alcoholism, drug addiction, and HIV disease). As with any crime victims, people with disabilities can be victims of domestic violence, child abuse, sexual assault, homicide, fraud, and other types of crimes. They are victimized by family members, acquaintances, strangers, institutional personnel, and caregivers. Many are victimized multiple times. In addition to people who have been disabled since birth, some people are disabled as a result of violent assaults. Catastrophic physical injuries can result in loss of abilities to see, hear, touch, taste, feel, move, and think in the usual ways. Although statistics on crime-related physical injuries are imperfect, it has been estimated that at least 6 million serious injuries occur each year due to crime, resulting in either temporary or permanent disability. The National Rehabilitation Information Center (NARIC) has estimated that a large percentage—perhaps as many as 50 percent—of patients who are long-term residents of hospitals and specialized rehabilitation centers are there due to crime-related injuries. Those patients seldom receive outreach from a crime victim assistance or compensation program (National Organization for Victim Assistance [NOVA], 1998). Baladerian (2001) reports that individuals with disabilities number approximately 43 million, representing about12 percent of the population. “Those with disabilities do not have anywhere near the presence in the political scene. They are seen . . . or mostly unseen . . . only when there is a protest, or a White House event. This is still one of the most invisible minorities in the United States.” The Crime Victims With Disabilities Awareness Act of 1998 defines developmental disabilities as: A severe, chronic disability of an individual 5 years of age or older that is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the individual attains age 22; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning mobility; self-direction; capacity for independent living; and economic self-sufficiency; and reflects the individual’s need for a combination and sequence of special, interdisciplinary or generic services, support or other services that is of lifelong or extended duration.

Forensic Nursing

Baladerian says there are several misperceptions associated with persons with disabilities that can “hamper their due process of the law, and perpetuate stereotypes which often results in discrimination against people with disabilities.” The first myth is the perception that people with disabilities are “suffering.” She says that rather than extending legal rights and protections, as with other oppressed groups, a societal response prior to passage of the Americans with Disabilities Act (ADA) typically was to extend “charity.” Baladerian states, “Being kind to a person with a disability is not an acceptable substitute for the provision of civil rights protections.” The second myth is that people with disabilities lack the ability to make choices or determine for themselves what is best for them in all areas of life, including physical, mental, emotional, spiritual, political, sexual, and financial aspects. “Although individuals with severe cognitive impairments may need greater support and advocacy services, this does not impede their ability or preclude their right to participate actively in decisions affecting their lives,” Baladerian states. The third myth, according to crime victim advocates, is that many people in society fear contact with crime victims generally, as though their distresses are contagious. An even stronger stigma has been attached to those with disabilities. According to NOVA (1998): Society is not socialized to integrate differences in abilities as a part of people’s perception of “normality.” The cultural norms for functioning include good hearing and vision, physical independence and mobility, mental alertness, the ability to communicate primarily through the written and spoken word, and physical attractiveness. Deviations from those norms tend to frighten those in the “able-bodied majority” who define the concept of normal abilities.

Many individuals with disabling conditions are especially vulnerable to victimization because of their real or perceived inability to fight or flee, or to notify others and testify about the victimization. Frequently, because a person with a disability might be more physically frail, the victimization could exacerbate existing health or mental health problems. For those who hope that their disability might “protect” them from criminal victimization, it is shocking to learn that many criminals do not act on a perceived “desirability” of the intended victim, according to Baladerian, who adds that some perpetrators might be unaware that their victims have a disability. “Here, the victim is truly random, in the wrong place at the wrong time, although that victim’s ability to frustrate the criminal’s intent may be less than a person’s without a disability,” Baladerian (1997) writes. Another reality is that many offenders are motivated by a desire to obtain control over the victim and measure their potential prey for vulnerabilities. Many people with disabilities, because they

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are perceived as unable to physically defend themselves, identify the attacker, or call for help, are perfect targets for such offenders. People with disabilities are also vulnerable to abuse by the very professionals and other caregivers who provide them with services. Just as many pedophiles gravitate to youth-serving occupations, so do many other predators seek work as caregivers to people with disabilities. According to NOVA (1998), virtually half of the perpetrators of sexual abuse against people with disabilities gained access to their victims through disability services.

8.1.2 VICTIMIZATION

OF

son. Once, in a state of anger when he could not find her money, he flipped her over and she fell out of the bed onto the floor. She sustained several bruises but was not seen by a physician. She did not report the abuse or the theft to the police out of fear that her family would no longer want to care for her. These case studies illustrate the fact that persons with disabilities face unique obstacles, including the following: •

DISABLED INDIVIDUALS

Oktay and Tompkins (2004) describe a survey of 84 adults with disabilities who received personal assistance with activities of daily living from family members, informal providers, or agency personnel. Results showed that 30 percent reported mistreatment from their primary provider, and 61 percent reported mistreatment by another provider. Verbal abuse, physical abuse, and theft or extortion were the most common forms of mistreatment by primary providers. Verbal abuse, neglect, poor care, and theft were the most common forms of mistreatment by other providers. Adults with lower incomes were the most likely to experience mistreatment. Male providers were more likely to mistreat, as were inexperienced providers, and those who provided more than 50 hours of care per week. Studies have shown that 68 percent to 83 percent of women with developmental disabilities will be sexually assaulted in their lifetime, which represents a 50 percent higher rate than the rest of the population (NOVA, 1998). According to Pease and Frantz (1994) those with developmental disabilities are more likely to be revictimized by the same person and more than half never seek assistance from legal or treatment services. It is not just individuals with developmental disabilities who suffer very high rates of victimization. A study of psychiatric inpatients found that 81 percent had been physically or sexually assaulted. The 1998 NOVA study described several eye-opening case studies. In California, a woman was stabbed in the back during a robbery attempt. As a result of the assault, she became paraplegic. Unfortunately, neither the police nor hospital staff told her about victim assistance or independent living services. Because the assailant was never apprehended, the prosecutor-based victim assistance program did not provide her with services. In her anger and depression, she became suicidal. She survived a suicide attempt only because an alert nurse resuscitated her in time. In another case, an elderly woman who was unable to walk was cared for at home by family members. Her grandson, a drug user, frequently stole money from her, especially after the third of each month, when her Social Security disability income check arrived. The woman would tuck her money under her to hide it from her grand-

•

Isolation. Today’s society often segregates persons with disabilities through physical and social isolation, with institutionalization representing the extreme. As a result of pervasive isolation, people with disabilities might not learn about available services and resources, nor are they routinely informed of rights they have by law. This is particularly true for people with more severe disabling conditions, older people with disabilities, and younger people with developmental disabilities. Indeed, many individuals who are chronically victimized do not even know that society condemns such predatory conduct and has tools to end and redress that wrong. Limited access. In many instances, crime victims with disabilities do not have physical access to services. Architectural barriers in buildings and public transportation systems mean that many crime victims with disabilities cannot visit criminal justice agencies or victim assistance programs. The ADA addresses key issues of accessibility, but there is an extensive lack of understanding of how Titles II and III of the ADA pertain to the criminal justice and victim assistance fields. Moreover, this lack of understanding is frequently coupled with a fear that making services accessible to crime victims with disabilities will require expensive, disruptive adaptations.

Attitudes toward the person with a disability are as important or more so than physical accessibility. In addition to accessible physical environments, program staff must be welcoming toward people with disabilities and show in their demeanor and in the quality of their programs that they sincerely want to work collaboratively to serve the community. In 1999, a workshop was held to bring together policymakers from the Department if Justice, the Department of Health and Human Services, the Department of Education, and the California Department of Developmental Services. The discourse was eventually assembled into a report, Crime Victims With Developmental Disabilities: Report of a Workshop, a product of the Committee on Law and Justice of the Commission on Behavioral and Social

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Sciences and Education (CBSSCE) National Research Council (2001). The report draws on eight white papers presented at the event, and assembles a critical mass of current thought on the topic of violence toward persons with disabilities. At the forum, a presentation by the California Department of Developmental Services included a study that found during the past decade, while the state of California’s population increased by 20 percent, the number of persons with developmental disabilities doubled. Many of these individuals reside in communities where they receive little health care, have access to few social services, and are easy targets for violent crime. Disabilities come in many forms, and definitions of disability relate to physical, cognitive, or behavioral characteristics, as well as to the individual’s ability to perform specific functions. The report estimated that 2 percent of the U.S. population has mental retardation or a developmental disability, but it is only an estimate because the data do not reflect individuals in institutions, the correctional system, or the military. Violent crimes committed against people with disabilities include conventional violent crimes such as homicide, assault, theft, and robbery; abuse and neglect; family violence; and specialized crimes such as abduction; and noncriminal violent acts such as assaults by other children or sibling bullying. However, persons with disabilities are especially vulnerable to certain types of crimes. Anecdotal evidence suggests that they face unusually high risks of physical abuse and sexual assault. Studies from the United States, United Kingdom, Canada, and Australia confirm high rates of violence and abuse of disabled persons at the hands of caregivers. The report also estimated that 83 percent of women with developmental disabilities in their sample had been sexually assaulted, and of those, nearly 50 percent had been sexually assaulted 10 or more times. Wilson and Brewer (1992) found that 40 percent of crime against people with mild mental retardation went unreported, whereas 71 percent of crime against people with severe mental retardation went unreported. Crosse, Kaye, and Ratnofsky (1993) found that children with developmental disabilities were at twice the risk of physical and sexual abuse than children without such disabilities. Young et al. (1997) found that women with disabilities were significantly more at risk for suffering abuse by nonintimate caretakers, and that women with disabilities stay in abusive relationships for many of the same reasons women without disabilities do, including fear of further violence or retaliation, belief that the batterer will change, love of the abuser, having no economic support if they leave, and religious beliefs, among other concerns. However, women with disabilities have limitations on their ability to leave an abusive relationship in a caregiving situation, being hampered by not physically being able to leave, fear of losing caregiver service if the abuse is reported, and lack of resources to live independently.

Forensic Nursing

Baladerian (1999) writes, “While representing a significant percentage within the population, attention to issues affecting individuals with disabilities is almost none. This is particularly true regarding criminal victimization either as children or as adults. Reporting of crimes, investigations, prosecutions and even sentencing issues are major problems. Research of the victimization and data collection remains nearly nonexistent.” In 1991, the National Center on Child Abuse and Neglect, a branch of the Department of Health and Human Services, reported to Congress on the breadth and depth of the problem of abuse of the disabled. The study was conducted using a retrospective review of substantiated cases of child abuse in 36 departments of Child Protective Services (CPS) across the country. Their research found that children with disabilities are abused at approximately twice the rate of children who do not have disabilities. Baladerian says that CPS departments did not did not consistently identify or document the child’s disability, and adds, “It can be interpreted that the data are far from realistic due to these problems, and the well-known problem of under reporting and inadequate investigations.” She points to other studies that have demonstrated the incidence of abuse of children with disabilities to be anywhere from four to 10 times the rate among children. Researchers have documented the trend toward victims knowing their assailants. For both children and adults with disabilities, the perpetrator is well known to and trusted by the victim and/or the victim’s family. Perpetrators can include family members, friends of the family, service providers (transportation, personal assistants, teachers, teacher aides, workshop staff, supervisors, and counselors), one-on-one care providers, and professionals such as physicians and social workers, among others. Those with both frequent direct care responsibilities (daily staff) and those with more distant relationships (administrators) have been identified as perpetrators of abuse (Baladerian, 1999). Sexual abuse tends to be the most publicized form of abuse; however, other types of abuse, such as murder, physical assaults, and financial exploitation have received much less attention. Baladerian (1999) classifies perpetrators of abuse against individuals with developmental disabilities as being in the “nonstranger” category in 99 percent of the cases. In the general population, the rate is closer to 70 percent, depending on the type of crime. Authorities place emphasis on avoiding so-called “stranger danger,” although closer to home, a perpetrator might be the victim’s father, mother, personal care assistant, foster parent, residential program staff, or work supervisor.

8.1.3 A MEETING

OF THE

MINDS

A great amount of data on victimization of persons with disabilities came out of the Symposium on Working with Crime Victims With Disabilities, funded by the OVC and

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coordinated by NOVA. Held in January 1998 in Arlington, Virginia, the symposium brought together experts from the disability advocacy and victim assistance and research fields, who raised as many questions as they answered, thus opening the way for the victim assistance field to look more closely at a large and underserved crime victim population. As a result of their discussions, they developed recommendations for OVC and the victim assistance field on improving the response in serving crime victims with disabilities, which are discussed here for the benefit of health care providers struggling to understand this underserved and often “invisible” population. At this symposium, experts agreed on the following: •

•

•

Crime victims with disabilities have a higher risk of victimization than crime victims without disabilities, and face a greater risk of being revictimized, often at the hands of a caregiver or family member. Consequently, victims might not be in a position to report the crime without fear of retaliation from the care provider. A crime victim with a disability or a person who becomes disabled due to crime might not have the resources or the physical stamina to cope with the many delays and hurdles that typically occur in the criminal justice system. For example, if a victim is paralyzed as a result of a crime, the victim will be adjusting to this recent disability at the same time that he or she is interacting with the criminal justice system. The combination could be overwhelming. Child custody issues are typically complex in cases of domestic violence. When the victim has a disability, the issues can be further complicated. According to disability advocates, some courts have awarded custody to the batterer, based on an assumption that children might be better off with an able-bodied offender than with a victim who has a disability.

At the end of the two-day symposium, experts agreed on the following recommendations: •

Physical accessibility 1. Criminal justice agencies and victim assistance programs should receive training on the requirements of the ADA and should support its vigorous enforcement. Agencies and programs should take advantage of technical assistance provided by the federal government to help ensure enforcement of the ADA. Programs that are not required to abide by the letter of the law should commit to adhering to the spirit of the law. This will help to ensure equal access to the jus-

•

tice system, as called for by federal law and state constitutional amendments and statutes. 2. When full physical accessibility is not immediately achievable, criminal justice agencies and victim assistance programs should initiate transition planning that focuses on obtaining accessibility by a designated date. Public and nonprofit agencies should understand that development of compliance plans are typically mandated under Titles II and III of the ADA, and with some exceptions, compliance plans are required, not optional. These compliance plans serve as a roadmap for taking incremental steps to improve accessibility, even if complete implementation of the plan must be delayed. The victim assistance sector should join with disability advocates and representatives of the various populations within the community to conduct a community needs assessment survey to ensure that the compliance plan is appropriate and effective. Networking and cross-training 1. Criminal justice and victim assistance personnel should receive training on disabilities, including developing an understanding of disability cultures. Special efforts should be made to identify qualified victim advocates with disabilities as trainers. In addition, criminal justice agencies and victim assistance programs should enlist qualified people with a wide range of different disabilities to lead in all stages of policy development, decision making, program development, and service delivery for crime victims with disabilities from the time of the crime through case disposition and beyond. People with disabilities should be proactively recruited and trained to become volunteers and paid staff members in criminal justice-oriented programs, especially in system-based or private victim assistance programs. 2. Criminal justice agencies and victim assistance programs should reach out proactively to local disability service organizations. They should provide them with information about victim rights and services. The service organizations, in turn, can inform their constituents on how better to access the criminal justice system, particularly the victim assistance programs.

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3.

•

Criminal justice agencies and victim assistance programs must develop coalitions, cross-training, and joint training opportunities with disability advocacy and services programs to build better working relationships and to better understand the services each offer when working with people with disabilities. In some communities, this coalition could be formalized as an interagency team or coordinating council, including involvement of local or state governmental task forces on disabilities. Communities might wish to emulate the models developed within the domestic violence victim advocacy community. 4. Collaborative partnerships must also be fostered with other community-based entities, such as schools, social service agencies, citizen groups, and churches or synagogues. Utilizing the resources of the entire community will help to ensure that service delivery is seamless, more inclusive, and does not duplicate or waste limited resources. 5. Leaders in the victim assistance and disability advocacy fields should work together to develop and utilize innovative ways to communicate, such as e-mail listservs. These links would allow the timely sharing of information and ideas between disability groups and individuals with expertise in disability rights and services with similar experts in victim rights and services. Regional and state Web sites devoted to the needs of crime victims offer another way of fostering this exchange. Direct services 1. Agencies should implement or extend streamlined interviewing and intake procedures so that crime victims with disabilities, particularly those with cognitive or communications disabilities, do not have to bear repeated interviewing in different locations. A multidisciplinary approach involving a law enforcement officer, a prosecutor, a victim assistance specialist, and others, as needed, in victim-friendly environments would be more effective and cost-efficient. 2. Agencies should develop and implement specific protocols on disclosures, confidentiality, and safety for crime victims with disabilities, particularly where there is potential for retaliation by a caregiver or a disability services agency. For example,

3.

4.

5.

when a crime victim reports to a law enforcement officer (or, when it does not get reported to a police agency, to a victim advocate) that he or she is being victimized by a caregiver and has reason to fear for his or her safety, that victim should be provided with assistance to relocate if necessary and have emergency replacement caregiver services provided. Criminal justice agencies and victim assistance programs should be proactive in acquiring assistive technology that would help crime victims with disabilities to be informed, present, heard, and understood more effectively when they communicate with law enforcement officers, prosecutors, judges, and victim advocates. For example, victim assistance service providers should know what accommodations will be needed so that a person with a communication disability can make a victim impact statement at the time of sentencing. Assistive technology and accommodations costs (i.e., for computer software, sign language interpreters, paratransit, etc.) should be considered part of the cost of “doing business.” Victim assistance agencies should be aware that under federal victim of crimes act (VOCA) guidelines, VOCA funds can be used to make services accessible to victims with disabilities. Specific allowable costs include the purchase of items such as Braille equipment or TTY/TTD machines, or for minor building improvements that make services more accessible to victims with disabilities. Once the agency is accessible and staff is trained, criminal justice agencies and victim assistance programs should publicize their ability to work with crime victims with disabilities by putting the universal symbol of access (the line drawing of a wheelchair) and a TTY/TTD number on all literature, promotional materials, business cards, and so on, used by the agency. Victim assistance and criminal justice agencies should incorporate into existing policies, procedures, and protocols the specific inclusion of persons with disabilities who are victims or witnesses of domestic violence, sexual violence, child abuse, impaired driving crashes, survivors of homicide victims, or other violent personal crimes. Parallel policies should be written

Vulnerable Populations

6.

7.

8.

to cover economic crimes committed against people with disabilities. Statistical information about crime victims with disabilities should be systematically collected by criminal justice agencies and victim assistance programs, using the ADA to define disability status. Prosecutors should invoke hate crimes statutes, if indicated, when prosecuting crimes against people with disabilities. Judges should apply equal sentencing or sentencing enhancements, when allowed, for offenders who victimize people with disabilities. When a violent personal crime occurs against a person with a disability who is institutionalized, the investigation of the crime should not be handled administratively or informally by the institution’s own investigators. Several studies suggest that 80 percent to 85 percent of criminal abuse of residents of institutions (an estimated 2.3 million people) never is brought to the attention of law enforcement authorities. Criminal prosecution should be pursued in cases of violent crime.

8.1.4 UNDERREPORTING AMONG DISABLED VICTIMS AND INTERFACE WITH THE CRIMINAL JUSTICE SYSTEM Experts say that historically, all victims of crime have been denied full participation in the criminal justice process. Crime victims with disabilities and their families are even less likely to reap the benefits of the criminal justice system. Disability advocates report that crimes against people with disabilities are often not reported to police. Of those that lead to an investigation and an arrest, very few are prosecuted. When proceeding through the criminal justice process, few victims with disabilities come into contact with a crime victim advocate. Often when victim services are provided, they might be inappropriate due to inadequate training of victim service providers. As with most types of crime and crime victims, underreporting of crimes perpetrated against people with disabilities is a major problem. Currently there is no authoritative research that details how many individuals with a disability become crime victims or how many people become disabled by criminal attacks. Nor has the victim assistance field adequately identified the best practices for serving victims with unique needs or how to train criminal justice system personnel—including victim specialists—and health care providers to make services truly accessible to all crime victims.

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Underreporting of crime is a pervasive problem that victim assistance advocates are addressing on many fronts. For example, RAINN estimates that 1,000 rapes occur every day in the United States, but only about 300 will ever be reported to the police. A crime might go unreported for many reasons: mobility or communication barriers, the social or physical isolation of the victim, a victim’s normal feelings of shame and self-blame, ignorance of the justice system, or the perpetrator is a family member or primary caregiver. In crimes involving a victim with a disability, one or more of these factors might prevent the crime from ever being reported. When the crime is reported, the reporting agency often fails to note that the victim had a disability, especially if the crime is reported by someone other than the victim. Later, assumptions and prejudice about the reliability of the testimony of victims with disabilities can deny them access to justice in the courts. Despite progress by disability rights activists, advocacy on their own behalf is still limited. Again, just as with many crime victims, a person who wants to access criminal justice decision-making processes is unable to do so without the adequate tools to enable full participation (NOVA, 1998). Limited information exists regarding the criminal victimization of people with disabilities, but the little that is available is horrifying in nature and scope. During the 1998 NOVA symposium, Joan Petersilia, a researcher and professor of criminology at the University of California, Irvine, stated that persons with developmental disabilities have a four- to ten-fold higher risk of becoming crime victims than persons without a disability, in her Report to the California Senate Public Safety Committee hearings on “Persons With Developmental Disabilities in the Criminal Justice System.” In addition, she says, “Children with any kind of disability are more than twice as likely as nondisabled children to be physically abused and almost twice as likely to be sexually abused.” Others in the field recount anecdotal experiences from their work that illustrate that crimes against people with disabilities are often extremely violent and calculatedly intended to injure, control, and humiliate the victim. There are many reasons why crimes against persons with disabilities go unreported. A significant obstacle to reporting is the victim’s fear of not being believed or taken seriously. Hickman (1998, as cited in NOVA, 1998), Roeher (1994, as cited in NOVA, 1998), and Sanders (1997, as cited in NOVA, 1998) report that women with disabilities often have negative experiences with members of law enforcement, which makes it unlikely they would pursue future contact with them. The researchers also say police share many of the myths that the public holds about these individuals. Police might believe these victims lack credibility, and in turn, police departments often have to protocols with which to respond to these biases. Hickman (1998) suggests that police might dismiss a woman who

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has a speech impairment as drunk if she calls and asks for help. Underreporting is a significant problem, experts say, as children and adults with developmental disabilities, as well as mental illness, communications disorders, and learning disabilities, are not taught about what constitutes abuse or how to report it. Many individuals with developmental disabilities are not allowed access to the telephone, thus obstructing legitimate autonomous reporting (Baladerian, 1999). If a report is made, it is not likely to be reported by the perpetrator, but by someone who knows the victim and whom the victim has told about the abuse or who notices the victims’ behavior or physical wellbeing is compromised in some way. Either scenario is unlikely, according to Baladerian, and more likely is that the abuse is not noticed, reported, or known to anyone but the victim for many years, unless and until someone makes a direct inquiry. A related challenge is the fact that not all disability advocates support mandatory reporting of crimes against people with disabilities. An individual struggling to maintain independence might perceive mandatory reporting as excessive “protectionism,” whereas others believe that the legal requirement to report crimes against “vulnerable adults” is integral to ensuring their safety (NOVA, 1998). There is much improvement to be made in the way individuals with disabilities are interviewed when a report of abuse is filed. The first contact is usually with a member of law enforcement, and among child abuse experts, a police officer’s uniform is considered to be threatening or intimidating. Their presence can sometimes undermine the interview process. Baladerian (1999) discusses a case in Los Angeles County that illustrates the need for followup interviews to illicit much-needed details. Following an unsuccessful interview by police, the deputy district attorney interviewed the victim; this interview resulted in the filing of charges against the alleged perpetrator. In many cases, follow-up interviews are not conducted and the case is closed with an “unable to interview” or “interview inconclusive” remark. Baladerian writes: In the case cited here, it was only due to the insistence of the mother of the adult victim that further interviewing occurred. As it turns out, her adult child’s complaint was one of five, three of which had been made prior to the assaults this person experienced, and nothing had been done. The perseverance of this mother will in all likelihood be the one factor that most contributes to the conviction of this predator. In this case, the perpetrator is well known to the victim, being a work supervisor.

Baladerian points out that some interviewers have not been adequately trained in working with individuals with

Forensic Nursing

mental retardation, mental illness, communication and speech impairments, or other psychiatric or physical disabilities. Some victims have been dismissed as unable to be interviewed, and in some cases, everyone but the victim has been interviewed, leaving a wide margin for a miscarriage of justice: This problem arises from preconceived notions of the abilities of individuals identified and/or perceived as having a disability or inabilities to effectively participate in an information-gathering interview. Thus, feeble attempts are made, or the specific interviewing strategies that could be effective have not been used by the interviewer. And, the investigator or detective does not seek consultation or supervision assistance to assure that an effective interview is conducted—consultation with a specialist in forensic interviewing of individuals with disabilities, or with a specialist in the particular disability of the victim, or even someone who knows the victim and could provide information and strategies to use for the interview.

When a productive, effective interview takes place, Balderian (1999) says two things should happen simultaneously: A case is filed with the district attorney’s office for prosecution, and the victim is referred for a psychotherapy evaluation. “Since most trauma victims could benefit from at least a few sessions with a mental health provider who specializes in the treatment of trauma, the recommendation for a referral for evaluation for the appropriateness or need for treatment is indicated. Yet, it is the rare victim with a disability who is referred directly from the law enforcement agency to the victim’s assistance program, either for therapy or advocacy.” Very little research exists that documents the interaction of people with disabilities within the criminal justice system. Individuals can be involved in the court system in three different ways. They can be defendants in criminal cases, they can be witnesses to crimes allegedly committed by defendants against others, and they can be victims of crimes themselves. Capacity, which is considered to be a person’s inherent ability to make a rational decision or give meaningful consent, figures into the ability of a person with disabilities to participate in a court proceeding. When there is question as to a person’s competence as a participant, a competency hearing might be held. Determining if a witness or a victim is competent to testify does not mean that the testimony will necessarily be believed. It is for the trier of fact to determine if the witness’s testimony is credible. Capacity is particularly relevant to people with developmental disabilities who are victims of sexual assault and abuse. Every state’s rape law criminalizes sexual intercourse with a woman who lacks capacity or is unable to give consent; typically, state statutes define sexual offenses

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aggravated by the victim’s incapacity as those based on her ability to understand the nature of the sexual conduct or to appraise its consequences. A number of prosecutors are taking it on themselves to become better educated about and better prepared for handling cases involving disabled individuals. They have learned that to achieve a successful prosecution, individuals with disabilities should be viewed as any other person, highlighting the victim’s particular vulnerability to maltreatment. There are several erroneous approaches used by some prosecutors in the courtroom, including the following: •

•

Making the adolescent or adult with disabilities look like an infant, or identifying the person as having a “chronological” age of 30 but a “mental” age of 6. By assuming that the adult has never had grown-up experiences, the individual is erased and a story replaces the victim’s actual life and functioning skills. The use of mental age in psychological testing is designed for clinical application to address intellectual skills, not to be used to globally identify the individual’s adaptive skills, language abilities, hopes, dreams, and life abilities. When the victim has a developmental or communication disability, the prosecutor must remark on the distinction between having a communication disorder and having an intellectual impairment, as many individuals have communication difficulties and have no deficits intellectually (Baladerian, 1999). Use of the concept referred to as spread, the belief that if an individual has one disability he or she probably has others. These assumptions are based in societal prejudices that are ingrained and difficult to undo. In many cases, judge and jury have been lost due to this false belief on the part of the trier of fact; the victim could not be believed, even when clear evidence had been presented (Baladerian, 1999).

8.1.5 WOMEN WITH DISABILITIES VIOLENCE

AND

SEXUAL

Spies (1999) writes, “Society is uncomfortable with crime, victimization and disability. When these two factors are combined, an increased level of discomfort usually results. Therefore, when people with disabilities are victims of crime, they often do not receive adequate attention.” When it comes to violence, three assumptions are made about women with disabilities:

• •

•

People with disabilities are abused at a far greater rate than the general population. Family members, caregivers, and acquaintances, not strangers, are perpetrating a large percentage of the abuse. Often no one is told of the abuse. If a victim does tell someone, very often she is blamed and not believed.

Sobsey (1994) reported that 90 percent of the perpetrators are men known to female victims of violence. In 1990, the California State Department of Developmental Disability Studies found sexual abuse to occur at a rate of 50 percent to 90 percent for this population. Tyiska (1998) reported that catastrophic injuries as the result of violent assaults can trigger the loss of abilities to see, hear, touch, taste, feel, move, and think in the usual ways. A 1998 report by the National Clearinghouse on Family Violence in Canada states that women have cited violence by their husbands or intimate partner as causing a loss of vision or mobility. Kemp (1995) found that 81 percent of battered women suffered from some degree of PTSD.

8.1.6 CHILDREN WITH DISABILITIES

AND

VIOLENCE

Schilling and Schinke (1984) argue that children with mental retardation are at greater risk for abuse by parents and caregivers than other children because ordinary standards of care are insufficient for them, and Neutra (1977) said they are less protected from incest than other children. Also, some children with development disabilities exhibit behavior such as tantrums and noncompliance that negatively impact caregivers and increase the risk of abuse (Solomons, 1979). Some settings or specific caretaking roles set the stage for potential abuse. Finkelhor (1988) suggests that the majority of day care abuse occurs around toileting activity, while a study of deaf children found that sexual abuse tended to occur as a result of caretaker access to residents in private settings such as bathrooms and bedrooms at residential facilities (Sullivan, 1987). Disabilities can also result from an act of violence or some other form of child maltreatment. It is estimated that approximately 33 percent of all spinal cord injuries are the result of intentional violence, although it was not known if there were other preexisting disabilities among those who suffered injury (Waters, 1996). Additionally, approximately 50,000 adolescents sustain permanent disability as the result of brain injury (Stylianos, 1998). Institutional abuse is another challenge, as approximately 2 percent of 4.5 million children with disabilities in the United States live in institutions. Brookhouser (1987) and Sullivan (1987)

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suggest that residential placement is a risk factor for experiencing physical or sexual abuse. For persons with disabilities to receive adequate services and support, Spies (1999) says the following issues must be addressed: •

•

•

•

•

•

• •

•

•

•

•

Active enforcement of existing discrimination laws (i.e., federally funded shelters for battered women need to be responsible for providing adequate services to women and children with disabilities). Grievance procedures need to be responsive to complaints about discrimination based on disability. When protocols are developed outlining the process that will be used when a person with a disability is victimized, they must be taken seriously. Persons with disabilities must determine what those protocols will be and must be in charge of their development. The disability community must apply pressure to home health agencies, rehabilitation facilities, independent living centers, hospitals, nursing homes, social services, and medical personnel to acknowledge the existence of physical, sexual, and psychological abuse against people with disabilities. More attention must be given by policymakers to the needs of the disability community and studies need to be funded to research the true extent of the problem. There must be increased funding for victim service programs to make them more accessible. Line items for accessibility provisions need to be included in budgets. Programs must seek in-service training on disability issues to reduce fear and ignorance. Medical providers who treat crime victims must be educated to ensure that people with severe disabilities receive appropriate medical treatment, safely and with dignity. There must be recognition by all parties that women with disabilities face double discrimination. There must be recognition that individuals with disabilities are being excluded from meetings, conferences, and events because of inaccessibility. The persons-with-disabilities culture must be recognized and honored, as disability is not a medical issue, but a civil rights issue. Service providers and policymaking bodies must have people with disabilities on their boards of directors and we must be involved in all levels of operation.

8.2 VIOLENCE AGAINST MEN About 3 percent of American men, or a total of 2.78 million men, have experienced an attempted or completed rape in their lifetime, according to the Prevalence, Incidence and Consequences of Violence Against Women report (Tjaden & Thoennes, 1998); in 2002, one in every eight rape victims were male, according to the U.S. Department of Justice NCVS (2002). Although males are not seen by many as a vulnerable population, the act of male sexual abuse is still considered a taboo subject in numerous communities. It is a crime with a justice process that is hampered by the fear of stigmas and underreporting to law enforcement and health care providers. It is crucial for FNEs to recognize that male victims of sexual violence do exist, and to be watchful for signs and symptoms of injury when these victims present to the clinical setting. Men most commonly experience sexual violence in the form of: • • • •

Receptive anal intercourse Forced masturbation of the perpetrator Receptive oral sex Forced masturbation of the victim

Sexual violence against males is underreported, far more than in the case of women, largely because of the reluctance of men to report acts of sexual violence to the police. This in turn is likely to be due to extreme embarrassment experienced by most males at being a victim of sexual violence. There are, however, certain settings in which acts of sexual violence against males might be more prevalent; for example, in prisons and the armed forces. Generally speaking, men have the same physical and psychological responses to sexual violence as women, including the following: • • • • •

Fear Depression Suicidal ideation Anger Sexual and relationship problems

Men also experience RTS in much the same way as women. However, men are likely to be particularly concerned about: • • • •

Their masculinity Their sexuality Opinions of other people (i.e., afraid that others will think they are homosexual) The fact that they were unable to prevent the rape

These concerns about masculinity and sexuality might stem from the misconceptions that only homosexual men

Vulnerable Populations

are raped and that heterosexual men would never rape another heterosexual man. Julia M. Whealin, PhD, asserts that at least 10 percent of men in the United States have suffered from trauma as a result of sexual assault. “Like women, men who experience sexual assault may suffer from depression, PTSD, and other emotional problems as a result. However, because men and women have different life experiences due to their different gender roles, emotional symptoms following trauma can look different in men than they do in women.” Perpetrators of male sexual assault differ in a number of ways from those who assault only females. Boys are more likely than girls to be sexually abused by strangers or by authority figures in organizations such as schools, churches, or athletics programs. Those who sexually assault males usually choose young men and male adolescents (the average age is 17 years old) as their victims and are more likely to assault many victims, compared to those who sexually assault females. Perpetrators often assault young males in isolated areas where help is not readily available. For instance, a perpetrator who assaults males might pick up a teenage hitchhiker on a remote road or find some other way to isolate his intended victim. As is true about those who assault and sexually abuse women and girls, most perpetrators of males are men. Specifically, men are perpetrators in about 86 percent of male victimization cases, Whealin says. Despite the popular belief that only gay men would sexually assault men or boys, most male perpetrators identify themselves as heterosexuals and often have consensual sexual relationships with women. Particularly when the assailant is a woman, the impact of sexual assault on men might be downplayed by professionals and the public. However, men who have early sexual experiences with adults report problems in various areas at a much higher rate than those who do not. Men and boys who have been sexually assaulted are more likely to suffer from PTSD, other anxiety disorders, and depression than those who have never been abused sexually. Men who have been sexually assaulted have a high incidence of alcohol and drug use. For example, the probability for alcohol problems in adulthood is about 80 percent for men who have experienced sexual abuse, as compared to 11 percent for men who have never been sexually abused, Whealin says. One study revealed that a percentage of boys who suffer from bowel incontinence had been sexually abused. Exposure to sexual trauma can lead to risk-taking behavior during adolescence, such as running away and other delinquent behaviors. Having been sexually assaulted also makes boys more likely to engage in behaviors that put them at risk for contracting HIV (such as having sex without using condoms). Gender socialization has been found to affect the recognition of male sexual assault. Men who have not dealt with the symptoms of their sexual assault might experi-

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ence confusion about their sexuality and role as men (their gender role). This confusion occurs for many reasons. The traditional gender role for men in the American cultures dictates that they be strong, self-reliant, and in control. Our culture traditionally does not recognize that men and boys can also be victims. Boys and men might be taught that being victimized implies that they are weak and, thus, not men. Furthermore, when the perpetrator of a sexual assault is a man, feelings of shame, stigmatization, and negative reactions from others might also result from the social taboos. When the perpetrator of a sexual assault is a woman, some people do not take the assault seriously, and men might feel as though they are unheard and unrecognized as victims. Parents often know very little about male sexual assault and might harm their male children who are sexually abused by downplaying or denying the experience. Whealin says that because of their experience of sexual assault, some men attempt to prove their masculinity by becoming hypermasculine. For example, some men deal with their experience of sexual assault by having multiple female sexual partners or engaging in dangerous “macho” behaviors to prove their masculinity. Parents of boys who have been sexually abused might inadvertently encourage this process. Men who acknowledge their assault might have to struggle with feeling ignored and invalidated by others who do not recognize that men can also be victimized. Because of ignorance and myths about sexual abuse, men sometimes fear that the sexual assault by another man will cause them to become gay. This belief is false. Sexual assault does not cause someone to have a particular sexual orientation. Because of these various gender-related issues, men are more likely than women to feel ashamed of the assault, to not talk about it, and to not seek help from professionals. Another myth that male victims of sexual assault face is the assumption that they will become abusers themselves. For instance, they might have heard that survivors of sexual abuse tend to repeat the cycle of abuse by abusing children themselves. Some research has shown that men who were sexually abused by men during their childhood have a greater number of sexual thoughts and fantasies about sexual contact with male children and adolescents. However, it is important to know that most male victims of child sexual abuse do not become sex offenders. Furthermore, many male perpetrators do not have a history of child sexual abuse. Rather, sexual offenders more often grew up in families in which they suffered from several other forms of abuse, such as physical and emotional. Men who assault others also have difficulty with empathy, and thus put their own needs above the needs of their victims. Health care providers should realize that men who have been assaulted often feel stigmatized, which can be the most damaging aspect of the assault. It is important for men to discuss the assault with a caring and unbiased support person, whether that person is a

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friend, clergyman, or clinician. However, it is vital that this person be knowledgeable about sexual assault and men. A local rape crisis center might be able to refer men to mental health practitioners who are well-informed about the needs of male sexual assault victims.

8.2.1 MALE VICTIMS OF SEXUAL ASSAULT: A REVIEW OF THE LITERATURE McLean, Balding, and White (2004) report that male-onmale rapes and sexual assaults comprise fewer than 10 percent of such assaults reported to the police, so many physicians seldom encounter them. The researchers sought to explore the nature of sexual assault encountered by males, ensuing injuries, and comparisons with male-onfemale assault cases. Their retrospective epidemiological study was conducted on two cohorts seen at St. Mary’s Sexual Assault Referral Centre in Manchester, England, between October 1986 and mid-May 2003: 376 male eases (370 individual clients) and 7,789 female cases (7,403 individual clients). The main outcome measure was the presence of injury (abrasion, laceration, or bruise) to defined body areas. The researchers found that 66 percent of male cases (when assault type was known) had been raped, significantly fewer than in female cases (95 percent). Eighteen percent of male cases that had a forensic medical examination presented with an anal injury; there were significantly more in females. Significantly fewer males than females sustained injuries to other body areas. Their conclusion was that males were significantly more likely (six times) than females to receive at least one injury to the anal area. Even so, males are five times more likely to have no anal injury, they reported. Stermac, Del Bove, and Addison (2004) examined victim and assault characteristics and the nature and extent of coercion, violence, and physical injuries among adult male victims of sexual assaults. Client records of three groups presenting to a sexual assault care center were included: males assaulted by a stranger (64), males assaulted by an acquaintance (81), and females assaulted by an acquaintance (106). The researchers found that male victims of sexual assault tended to be young, single men who reported high rates of vulnerabilities such as homelessness and physical, psychiatric, and cognitive disabilities. They also found that male stranger assailant victims were more likely to experience assaults involving weapons and physical violence, and that injuries sustained by victims and services delivered at the sexual assault care center were similar for both male and female clients. Lipscomb, Muram, Speck, and Mercer (1992) compared the demographics, physical findings, and assault characteristics of incarcerated, sexually assaulted men with those of nonincarcerated, sexually assaulted men. A case series of 99 adult male victims of sexual assault was evaluated over a three-year period at the Memphis Sexual

Forensic Nursing

Assault Resource Center, a nonhospital-based clinic that serves as the primary resource for sexually assaulted victims in the Memphis and Shelby County, Tennessee area. All adult male victims of sexual assault evaluated during the study period were included in the study; 99 victims were studied, including 80 incarcerated men and 19 men from the community. The researchers discovered that victims of sexual assault in the community group were older than the victims in the incarcerated group. Apart from the age difference and weapon use, there were no statistically significant differences between the incarcerated and nonincarcerated victims. The researchers concluded that the similarities between the two groups suggest that sexual assault of men might not be unique to prisons, and all men are potential victims. They added that further studies are required to better understand these crimes and to develop education and prevention programs. King and Woollett (1997) investigated the nature of sexual assault on men and their help seeking following the assault. The study encompassed all men who were seen at least once for face-to-face counseling at Survivors, a counseling service for male victims. Data on 115 men were analyzed; 69 were assaulted while under age 16.The average time from assault to contact with Survivors was 16.4 years. Fifty-one men (44 percent) were assaulted more than once. The assailant was known to the victim in all but 16 cases. One hundred men (87 percent) were assaulted by at least one man, seven (6 percent) by a man and a woman, and eight (7 percent) by women. Forced anal penetration took place in 88 cases. Twenty-seven men (23 percent) said they feared for their lives during the assault; 88 men (79 percent) sought no help and only 17 men (15 percent) reported the assault to police. For victims assaulted under the age of 16, the assault was more likely to be their first sexual experience and they were more likely to delay contact with Survivors for more than 17 years. They were also less likely to report to police. Victims assaulted by more than one person were more likely to have been assaulted by strangers, by women, and to have suffered physical harm; they were less likely to have experienced the assault as their first sexual experience, the researchers reported. Coxell and King (1996) reviewed sexual assault prevalence data from 1,480 males and found that these victims suffer from PTSD, sexual problems, difficulties forming close relationships, mistrust of adult men, suicide attempts, confusion about sexual orientation, and various mood disorders. Darves-Bornoz, Choquet, Ledoux, and Manfredi (1998) reported on a nationwide survey of school-age adolescents in France. In all, 121 boys and 344 girls reported having been sexually assaulted (mean age = 15.4 years). Results indicated that girls exhibited more somatic symptoms and mood disorders, whereas boys more frequently demonstrated behavioral symptoms such

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as running away, suicide attempts, violent outbursts, and substance use. Hodge and Canter (1998) report on two different accounts of male sexual assault in the literature. The first view is that rapes are perpetrated by homosexual offenders. The other view is that rape is predominantly an example of heterosexual violence. This paper reports on the results of a study constructed to explore both possibilities. Data from 83 male sexual assault victims and 36 investigated police reports was reviewed. Results indicated that homosexual offenders knew their victims for some time and targeted males under the age of 25 years. Heterosexual offenders were more likely to attack strangers of all ages and tended to operate in gangs. Consistent with the literature on the rape of females, the data indicated that acquaintance rape was less likely to be reported to the police. Isely, Busse, and Isely (1998) report that adolescent males, 16 years of age and older, are at risk of sexual assault. The sexual assault of adolescent males, however, has not been thoroughly explored. Much like sexually abused children, these survivors display significant emotional difficulties as a consequence of the sexual assault. An awareness of this type of abuse might assist in the early identification and treatment of this unacknowledged population. Isely and Gehrenbeck-Shim (1997) report on an attempt to determine the extent of male sexual assault. Agencies that work with sexual assault victims reported contact with 3,635 men who had sought treatment for sexual assault. Most assaults occurred between the ages of 16 and 30 years and a majority of these men experienced symptoms of PTSD. King and Woollett (1997) collected data on 115 male sexual assault victims who were seen at least once for face-to-face counseling. Analysis revealed that 69 men were assaulted prior to age 16. The average time from assault to obtaining counseling services was 16.4 years. Fifty-one men were assaulted more than once. The victim knew the perpetrator in the majority of cases. One-hundred respondents were assaulted by one or more men. Of the sample, 88 men did not seek help at the time and only 17 men reported the assault to the police. Victims under the age of 16 who were assaulted were more likely to report that this was their first sexual experience. Victims under the age of 16 were also more likely to delay contact with counseling and less likely to report to police. Victims assaulted by more than one person were less likely to have experienced the incident as their first sexual experience, and more likely to have been assaulted by strangers and to have suffered physical injuries. Stermac, Sheridan, Davidson, and Dunn (1996) studied the incidence and characteristics of sexual assault against 29 males (aged 18–65 years) who were seen in a crisis unit. The men’s personal history, demographic, and assault information were reviewed. Results showed that 86 percent of the sexual assaults involved male perpetrators, one

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involved a female perpetrator, and two involved both. Within this sample, 50 percent of the male–male assaults and both of the female–male assaults involved friends or acquaintances. Most victims were young gay men, many of whom had cognitive or physical disabilities that made them vulnerable; however, only a few of the stranger assaults appeared to be related to antigay violence. Vearnals and Campbell (2001) discussed the surprising fact that recently in the United Kingdom, males were incorporated into the legal definition of rape. Prior to that, it was legally impossible for a male to be a victim of sexual assault. Not only in the United Kingdom, but worldwide, the issue of male sexual assault is underaddressed. The authors discuss the health consequences of sexual assault and the lack of research in this area, and they stress the need for appropriate treatment interventions for victims. Further research is urged in this area, especially in the epidemiology of sexual assault; the emotional, physical, and psychological consequences; and the most effective psychological interventions.

8.3 VIOLENCE AGAINST LGTB INDIVIDUALS Health care providers must also be aware of sexual victimization within the LGTB communities. In 2003, 12 member organizations of the National Coalition of AntiViolence Programs (NCAVP) documented a record 6,523 LGTB domestic violence incidents reported in 11 cities and regions across the United States and in Toronto, Canada. This figure represents a 13 percent increase over the 5,718 cases reported by the same agencies in 2002, and includes six reported domestic-violence-related deaths. A significant large majority (4,964 or 76 percent) of incidents were reported in Los Angeles, a region that accounts for almost 93 percent of the net growth in LGTB domestic violence cases reported nationally in 2003. A disproportionate number of cases can be attributed to the presence of a large number of NCAVP member organizations, the availability of equal legal standing and remedies for LGTB domestic violence victims, and unparalleled support for data collection and reporting by a network of affiliated domestic violence law enforcement and service providers, including police and county sheriff’s departments. Boston reported 290 cases, New York City reported 501 cases, and San Francisco reported 388 cases, all of which represented significant increases in the number of cases documented. In smaller regions, 2003 case numbers declined or barely changed at all. Examples include Chicago (65 cases and a decrease of 12.2 percent), Colorado (139 cases and a decrease of 2.8 percent), Pennsylvania (19 cases, and a decrease of 42.4 percent), and Burlington, Vermont (21 cases and a decrease of 24 percent). NCAVP’s newest domestic violence report contributor, Toronto, recorded 26

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cases, one more than the 25 it reported internally to NCAVP last year. A number of trends have been identified by the NCAVP. Increased public attention to the LGTB community, especially in connection with the debate over samegender marriage that heated up in 2004, appears to have spurred increases in the amount of bias and hate-motivated violence targeting LGTB individuals. Most of the agencies represented in the 2003 report assist victims of bias violence and hate crimes, so that nearly all have found it necessary to accommodate growth in services for these individuals. A second trend is new investments of funding and resources in domestic-violence services, especially outreach and public education campaigns needed to encourage victims to seek help. Experts say that the debate over gay marriage, and especially the threat of a constitutional amendment banning any civil recognition for LGTB unions, has prevented some LGTB individuals from reporting their experience of domestic violence. In the future, an increasing number of LGTB domestic violence victims might decide to endure a partner’s abuse for the sake of a marriage proposal, or even an actual marriage. Others might be more hesitant to come forward because they feel that being the victim of domestic violence will somehow harm their community’s struggle for advancement. Experts add that there is no evidence that LGTB domestic violence occurs with any more frequency, or has any worse outcomes, than domestic violence between heterosexuals.

8.3.1 MURDERS AND DOMESTIC-VIOLENCE-RELATED DEATHS IN LGTB COMMUNITIES NCAVP documented six murders or other deaths of individuals in the context of actual or suspected LGTB domestic violence in 2003, an increase of two deaths over 2002. Two cities and regions reported murders in 2003: Arizona, with one (none in 2002), and New York City with five (compared with just two in 2002). The following recaps of homicides and attempted homicides illustrate the violence within LGTB communities. In a community in rural Arizona, there was an attempted murder of one woman by her roommate, who was then shot and killed by police as she fled the scene. The victim sustained multiple gunshot wounds before managing to call 911 before lapsing into a coma. Her assailant escaped and was pursued by sheriff’s deputies. When the woman was stopped, she raised her weapon and was shot by a deputy. The perpetrator had previously spoken about the victim as her girlfriend and told acquaintances that they were in a relationship. When the victim regained consciousness, she denied there had been any romantic involvement between them. In Kansas City, Missouri, a 28-year-old man was charged with second-degree murder and armed criminal action in the death of a 22-year-old man. The assailant had threatened to kill the victim if the victim ended the

Forensic Nursing

relationship. The victim had rejected the assailant’s marriage proposal, and the next day, the assailant was seen moving out of the apartment both men shared. A few days later, the victim was reported missing by his family. An unidentified witness reported seeing the victim’s car early in the morning, and when police arrived at the vehicle’s location, they found his body in the car’s trunk. Police searched the apartment and found blood evidence in the main room and a blood trail leading out of the apartment to the parking lot. Blood was also found on the assailant’s shoes when police arrested him shortly thereafter. In New York City, a 38-year-old man was convicted of second-degree manslaughter and sentenced to 22 years to life in jail for fatally beating and stabbing his lover, a 32-year-old man, during an argument in their home. The assailant claimed that the victim was killed accidentally; however, medical examiners testified that the victim died from multiple skull fractures from a baseball bat and 17 stab wounds to the chest. Also in New York state, an 88year-old African American male was slashed across his neck while he was eating dinner. A neighbor found him dead in his home. The victim’s wallet was missing, but detectives found no evidence of a break-in. They did find photographs of nude men the victim had paid to pose for him. One of the men, age 29, who was the last individual photographed, admitted to having an ongoing intimate relationship with the victim. The young man confessed to killing the elderly man and pleaded guilty to seconddegree murder. Robbery, not domestic violence, was officially cited as the motivation for the murder. In a third New York case, a 53-year-old man died of a heart attack in a hospital four days after his roommate, a 51-year-old man, gouged out his eyes with his fingernails during a physical argument in the home that they shared. The men were reportedly arguing over a broken television antenna. Police arrived and arrested the assailant for assault. It is unclear whether the medical examiners linked the victim’s death to the assault, and the two men were referred to only as “longtime roommates” in media accounts. In Pittsburgh, a 15-year-old boy beat his 18-year-old brother on the head with a claw hammer approximately 18 times in the family’s home and dumped the body into a bathtub. The assailant then phoned a friend, who came to the home and found the body. The assailant and another friend, who was present during the assault, left the home while the victim was being rushed to the hospital. The victim died from severe head injuries. The perpetrator had reportedly met friends at a local mall and bragged about attacking his brother, referring to him as a “faggot.” The perpetrator also reportedly told friends that he wanted to kill his brother because he was gay and that he also wanted to kill his family. The assailant was convicted of both murder and conspiracy to commit murder; the friend who witnessed the assault was also convicted of first-degree murder.

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8.3.1.1 Gender of LGTB Victims Of the total 6,523 domestic violence incidents reported by NCAVP’s member organizations in 2003, the victims in 3,344 cases (44 percent) were identified as men, whereas those in 2,357 cases (36 percent) were identified as women. The next largest group (623 cases, or 9 percent) represents incidents in which information about the victim’s gender was not recorded. There was a smaller group of incidents (161 cases, or 2 percent) in which the victims were identified as transgender: either male to female (M–F), or female to male (F–M). A considerably larger number of victims were transgender M–F individuals (161) than F–M (31). Relative to the comparable figures for 2002, the numbers in nearly all of these categories show growth, some of it attributable to a compensating reduction (minus 27.3 percent) in the number of 2003 victims whose gender was reported unknown, especially in Los Angeles. Los Angeles also accounted for the bulk of growth reported nationally in the number of incidents involving victims who were male (an increase of 26 percent overall) and transgender (an increase of 33 percent overall). Within the transgender category, however, considerably higher growth was seen both in Los Angeles and nationally in the number of cases involving those who identified themselves as female (an increase of 44 percent) versus those who identified as male (an increase of 16 percent). However, this unequal growth alone cannot account for all of the continuing difference in size between the transgender M–F and F–M victim populations. Accordingly, although women made up a smaller overall proportion of domestic violence victims documented by NCAVP in 2003 than in 2002, little should be drawn from that fact. Among the other NCAVP agencies reporting increases in the number of domestic violence incidents in 2003, the tendency for most was to serve relatively higher proportions of women (and especially transgender M–F individuals) than in 2002. A significant exception was San Francisco, which reported a modest reduction in incidents involving women as victims (from 165 to 154) and significant growth among those involving men (from 168 to 196, or an increase of 16.7 percent). However, San Francisco also reported a 50 percent increase (from 18 to 27) in the number of transgender M–F victims between the two years. By contrast, at almost all of the NCAVP agencies reporting a decrease in the number of incidents, reductions involving women as victims were steeper than those involving men. This fact suggests that women might be more sensitive to limitations or constraints in LGTB domestic violence services, at least at these agencies. Another reason could be that some lesbian and bisexual women victimized by domestic violence find ways to obtain services from mainstream domestic violence orga-

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nizations. The question, like most others relating to LGTB domestic violence, begs further research. 8.3.1.2 Sexual Orientation of LGTB Victims As in past years, the great majority (5,374 cases, or 82 percent) of domestic violence incidents reported to NCAVP in 2003 involved victims who identified themselves as lesbian or gay. The next largest category (575 cases, or 9 percent) included cases in which a victim declined to specify a sexual orientation, or it wasn’t recorded. In 263 other instances (4 percent), the victims identified themselves as bisexual, and in an additional 44 cases (0.6 percent), they said they questioned their sexual orientation or weren’t sure. Self-identified heterosexuals (a category that can include transgender individuals) were the victims in 263 cases (4 percent), coincidentally the same number as were reported bisexual. Experts say these numbers encompass some curious changes with respect to the ones reported by NCAVP in 2002, but the significance of these changes is questionable. First, the proportion of incidents involving victims who identified themselves as lesbian or gay appeared to grow last year by six percentage points relative to 2002. Further, this trend was one of the few encountered by an actual majority of NCAVP members contributing to this report. Although some of the increase appears attributable to a decline in incidents involving victims whose sexual orientation was unknown, it cannot be fully accounted for in this way. The range of possible explanations for this shift, however, is large. Some of these explanations might appear positive: growing awareness of the problem of domestic violence among lesbians and gay men, for example, or an increased willingness to self-identify as such. However, it is also possible that the explanation is negative. Perhaps the higher concentration of self-identified LGTB clients encountered by NCAVP member agencies in 2003 means they are doing less well serving people and groups who might be at higher risk to experience domestic violence. These could include those who hide their sexual orientation, question it, or otherwise do not identify themselves in this way. Again, research is needed to shed light on all these possible explanations. 8.3.1.3 Ages of LGTB Victims In 2002, most NCAVP member agencies used an instrument in which victims’ ages were reported in several discrete categories: under 18, 18 to 22, 23 to 29, 30 to 44, 45 to 64, and 65 and over. In 2003, several (but not all) of NCAVP’s members switched to a new instrument with a different set of age categories: under 14, 15 to 18, 19 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and 80 and over. This makes it challenging to describe any but the most general trends in the age distribution of victims

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in 2003. In fact, the only valid way to compare age information using both sets of categories is to divide all the reported victims into just two age groups: those under 30, and those who are older. However, within these two categories, there appears to have been an unusually large change in 2003: The number of victims whose ages were under 30 grew to 1,472 from 954 in 2002 (an increase of 54 percent), whereas the number of those 30 and older increased by just one fifth of that rate (and less than the rate of growth in new cases overall), from 1,845 to 2,040. Further, this trend was general, experienced by all but four of the agencies reporting data this year (and in all but one of those agencies, the 2003 decline in younger victims was very modest). It should be noted that there remain a very large number of cases, nearly half of those reported in both years, in which the ages of victims were not recorded. However, because most of these cases are from a single city, Los Angeles, and because their number did not change significantly in 2003 (and actually declined as a percentage of the whole) it appears that a majority of NCAVP members are providing more domestic violence interventions for LGTB and questioning youth and young adults. In fact, many of NCAVP’s member organizations and affiliated programs have endeavored to develop services more appropriate for younger people over the past several years, and the figures in this report are the best indication yet of their success. 8.3.1.4 Race and Ethnicity of LGTB Victims NCAVP member agencies also attempt to record the race and ethnicity of victims of domestic violence incidents. They do this partly to measure how well their programs are providing accessible, sensitive services for all members of the LGTB community, but also because, in some instances, a victim’s racial or ethnic identity could become a weapon in the hands of abusers. However, as with other demographic questions, not all victims answer queries regarding their race or ethnicity, nor are these questions always appropriate to ask. NCAVP agencies reported the race and ethnicity of domestic violence victims in just 42 percent of all the incidents recorded in 2003. Of the victims for whom this information was known, 1,211 (44 percent) were White, 684 (25 percent) were Latino, 413 (15 percent) were people of African descent, 153 (5 percent) were Asian/Pacific Islander, and 125 (4 percent) were reported as multiracial. The number of known Asian/Pacific Islander victims grew by 104 percent over 2002, but virtually all of this increase occurred in Los Angeles. The number of known White victims declined by 11 percent, and the number of Latinos by 10 percent, but in these instances, too, most of the change was restricted to Los Angeles, and the experience of many of NCAVP’s members was the reverse. For example, in San

Forensic Nursing

Francisco, Chicago, Boston, New York and Toronto, the number of victims who were White increased slightly (albeit not necessarily as fast as increases in cases overall), and San Francisco, Colorado, Chicago, and New York reported increases in the number of Latino clients as well. Of note in the 2003 statistics collected by NCAVP is the number of domestic violence incidents recorded by its member agencies. This data suggests that such incidents continued to peak at three points throughout the course of the year: during May and June, when many are preparing to participate in annual LGTB pride celebrations around the country and LGTB organizational and program outreach reaches a peak; again in October during the observance of Domestic Violence Awareness Month; and once more with the new year.

8.3.2 THE HEALTH CARE PROVIDER’S RESPONSE TO LGTB VICTIMS The FVPF’s (2004) National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Healthcare Settings acknowledges that IPV occurs at similar rates in LGTB adolescent and adult populations as in heterosexual populations, with higher rates in male same-sex relationships than female. However, it is important to realize that the statistics might be low because those in same-sex relationships might not be comfortable stating their sexual preference. A policy to assess all patients should include specific recommendations for responding to LGTB and heterosexual victims. Specialized services might be limited in your area, so when unavailable, refer patients to national organizations or the national domestic violence hotline. Prior to implementing a program to assess all patients, it is important that health care providers do the following: • • •

•

•

•

Be aware of their own biases about who is a victim and homophobia. Call the local IPV program and determine what resources are available for LGTB clients. Call any local programs for LGTB communities and determine what resources they offer for victims of IPV. In addition (or if no programs exist in your area) provide LGTB victims with the national domestic violence hotline number for more information or materials. Have educational and safety materials available that are appropriate for LGTB victims. (For clinic materials go to the FVPF Web site at http://www.endabuse.org.). Refer gay male victims of IPV to Anti-Violence Project (AVP), Community United Against Violence (CUAV), Gay Men’s Domestic Violence

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•

Project, or other like organizations for information and support. Refer lesbian victims to CUAV, the Network for Battered Lesbians and Bisexual Women, AVP, or other local organizations for information and support.

8.4 VIOLENCE AGAINST ELDERS One of the most significant areas of opportunity for the contributions of forensic nurses is elder abuse. Griffin and Williams (1992) suggest that the effects of the baby boom and increased life expectancy have both contributed to the immediate and projected increase in the number of elderly Americans. Additionally, medical advances and the implementation of protective legislation have greatly increased the length of life for many Americans. However, generational changes in the family structure mean that fewer members of the elderly population are cared for by family members or friends; instead, this important task falls to strangers tasked with caring for an increasing number of individuals. According to the U.S. Bureau of the Census (2000), nearly 77 million people, more than a quarter of the total U.S. population, are 50 or older. By 2030, as baby boomers become the retiree majority, one third of American voters will be over 55, somewhere between a fifth and a quarter of them over 65. Issues of elder abuse are of significant interest to baby boomers who have aging parents, as well as those who themselves face issues of aging and victimization. Between now and 2030, the number of adults over 65 will double to more than 70 million, from 12 percent of the population to more than 21 percent. The health care system, crippled by an intense shortage of nurses, might not be prepared to bear this skyrocketing number of admissions into acute care, subacute care, and long-term care facilities. Koenig and Deguerre (2005) state that older Americans constitute the fastest growing segment of the U.S. population and might account for 20 percent of the U.S. population by 2050. They assert that the federal government has taken minimal action to identify and solve elders’ problems. Due to the federal government’s inaction, states have become the primary engine for combating abuse. They say this is most often seen through adult protective services (APS), which primarily consist of mandatory reporting laws, involuntary interventions, and educational programs. Koenig and Deguerre add that funding is the primary roadblock to the successful execution of state laws targeting domestic elder abuse. They say that the proposed federal Elder Justice Act of 2003, if passed, might fill in the gaps of current federal legislation by implementing a uniform method of response to domestic elder abuse and providing funding to the states to rectify instances of abuse. (This piece of legislation is discussed later in this chapter.)

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“Elder abuse is where we were with child abuse about 20 years ago,” asserts Diana Faugno, RN, BSN, CPN, SANE: I think there is a lot more that needs to be done for this special population. When you think about it, we are all getting older. We need nurses who are specialists in gerontology, who can spot the many types of elder abuse and neglect, from verbal and physical abuse to fiduciary abuse, and help victims feel comfortable with reporting the abuse. Victims are scared to death to tell. They are intimidated, so they back off, and the cycle of abuse continues. We need nurses who have that basic forensic knowledge, and see the red flags of elder abuse.

8.4.1 IMPORTANCE OF ENDING AGEISM INCREASES AS LIFE EXPECTANCY LENGTHENS The U.S. Bureau of the Census also estimates that by the year 2050, approximately 25 percent of Americans will be over the age of 65, yet the U.S. culture has done little to eliminate the one accepted prejudice that could relegate one quarter of the population to second-class citizenship: ageism. As the U.S. population continues to age, the need to halt ageism and ageist practices becomes more urgent, according to the recently published issue brief by the International Longevity Center USA, an independent affiliate of Mount Sinai School of Medicine, titled, “The Future of Ageism.” Ageism, like racism and sexism, is prejudice and discrimination against members of a group—in this case, older individuals. It is a universal prejudice, because increased longevity means that all individuals can eventually become its victims. Unlike racism and sexism, it is rarely discussed through public discourse. It is a relatively new concept first noted in 1969 by Robert N. Butler, MD, president and CEO of the ILC-USA.

8.4.2 PAINTING ELDERS

A

PICTURE

OF

VIOLENCE AGAINST

Look in 10 different places for statistics on elder abuse, and you will undoubtedly find 10 different sets of figures. The NCVS of the Bureau of Justice Statistics (2001) reported that the rate of violent crime victimization of persons ages 65 or older was about four per 1,000. Persons ages 65 or older numbered 34.5 million in 1999, about 13 percent of the U.S. population, according to the Administration on Aging (2000). The 1998 National Elder Abuse Incident Study (NEAIS) reports that an estimated total of 551,011 elderly persons aged 60 and over experienced abuse, neglect, or self-neglect in domestic settings in 1996. The most frequent forms of elder abuse reported to APS agencies included neglect (48.7 percent), emotional or psychological abuse (35.4 percent), financial or material exploitation (30.2 percent), physical abuse (25.6 percent), and abandonment (3.5 percent), according

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to the National Center on Elder Abuse (NCEA). The agency also reports that adult children are the largest perpetrators of elder abuse (47.3 percent), followed by spouses (19.3 percent), other relatives (8.8 percent), and grandchildren (8.6 percent). The definitions and statistics regarding elder abuse vary. They range from estimates that one out of 10 persons living with a family member is subject to abuse—approximately 2.5 million a year (Griffin & Williams, 1992)—to 1 in 25 elderly persons being victimized annually (Heisler, 1991). Other studies suggest that 3.6 percent of elderly citizens are victims of abuse each year (Commonwealth of Pennsylvania, 1988). According to the NCEA, the major types of elder abuse are categorized as follows: •

•

Physical abuse is defined as the use of physical force that can result in bodily injury, physical pain, or impairment. Physical abuse can include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, and physical punishment of any kind also are examples of physical abuse. Signs and symptoms of physical abuse include but are not limited to: • Bruises, black eyes, welts, lacerations, and rope marks • Bone fractures, broken bones, and skull fractures • Open wounds, cuts, punctures, and untreated injuries in various stages of healing • Sprains, dislocations, and internal injuries or bleeding • Broken eyeglasses or frames, physical signs of being subjected to punishment, and signs of being restrained • Laboratory findings of medication overdose or underutilization of prescribed drugs • An elder’s report of being hit, slapped, kicked, or mistreated • An elder’s sudden change in behavior • The caregiver’s refusal to allow visitors to see an elder alone Sexual abuse is defined as nonconsensual sexual contact of any kind with an elderly person. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes, but is not limited to, unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing. Signs and symptoms of sexual abuse include but are not limited to the following:

•

•

• Bruises around the breasts or genital area • Unexplained venereal disease or genital infections • Unexplained vaginal or anal bleeding • Torn, stained, or bloody underclothing • An elder’s report of being sexually assaulted or raped Emotional or psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional or psychological abuse includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation, and harassment. In addition, treating an older person like an infant; isolating an elderly person from his or her family, friends, or regular activities; giving an older person the silent treatment; and enforced social isolation are examples of emotional and psychological abuse. Signs and symptoms of emotional and psychological abuse include but are not limited to the following: • Being emotionally upset or agitated • Being extremely withdrawn and noncommunicative or nonresponsive • Unusual behavior usually attributed to dementia (e.g., sucking, biting, rocking) • An elder’s report of being verbally or emotionally mistreated Neglect is defined as the refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Neglect can also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care. Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-on responsibility to an elder. Signs and symptoms of neglect include but are not limited to the following: • Dehydration, malnutrition, untreated bed sores, and poor personal hygiene • Unattended or untreated health problems • Hazardous or unsafe living condition or arrangements (e.g., improper wiring, no heat, or no running water) • Unsanitary and unclean living conditions (e.g., dirt, fleas, lice on person, soiled bedding, fecal or urine smell, inadequate clothing) • An elder’s report of being mistreated

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•

•

•

Abandonment is defined as the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder or physical custody of an elder. Signs and symptoms of abandonment include but are not limited to the following: • The desertion of an elder at a hospital, a nursing facility, or other similar institution • The desertion of an elder at a shopping center or other public location • An elder’s own report of being abandoned Financial or material exploitation is defined as the illegal or improper use of an elder’s funds, property, or assets. Examples include, but are not limited to, cashing an elderly person’s checks without authorization or permission; forging an older person’s signature; misusing or stealing an older person’s money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney. Signs and symptoms of financial or material exploitation include but are not limited to the following: • Sudden changes in bank accounts or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the elder • The inclusion of additional names on an elder’s bank signature card • Unauthorized withdrawal of the elder’s funds using his or her ATM card • Abrupt changes in a will or other financial documents • Unexplained disappearance of funds or valuable possessions • Substandard care being provided or bills unpaid despite the availability of adequate financial resources • Discovery of an elder’s signature being forged for financial transactions or for the titles of his or her possessions • Sudden appearance of previously uninvolved relatives claiming their rights to an elder’s affairs and possessions • Unexplained sudden transfer of assets to a family member or someone outside the family • The provision of unnecessary services • An elder’s report of financial exploitation Self-neglect is characterized as the behavior of an elderly person that threatens his or her own health or safety. Self-neglect generally manifests itself in an older person as a refusal or failure to provide himself or herself with adequate food, water, clothing, shelter, personal

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hygiene, medication (when indicated), and safety precautions. The definition of selfneglect excludes a situation in which a mentally competent older person, who understands the consequences of his or her decisions, makes a conscious and voluntary decision to engage in acts that threaten his or her health or safety as a matter of personal choice. Signs and symptoms of self-neglect include but are not limited to the following: • Dehydration, malnutrition, untreated or improperly attended medical conditions, and poor personal hygiene • Hazardous or unsafe living conditions or arrangements (e.g., improper wiring, no indoor plumbing, no heat, no running water) • Unsanitary or unclean living quarters (e.g., animal or insect infestation, no functioning toilet, fecal or urine smell) • Inappropriate or inadequate clothing, lack of the necessary medical aids (e.g., eyeglasses, hearing aids, dentures) • Grossly inadequate housing or homelessness 8.4.2.1 Prevalence and Incidence of Elder Abuse The NCEA, in its April 2005 Fact Sheet on Elder Abuse Prevalence and Incidence, states, “No one knows precisely how many older Americans are being abused, neglected, or exploited. While evidence accumulated to date suggests that many thousands have been harmed, there are no official national statistics.” The agency points to several reasons, including: •

• •

Definitions of elder abuse vary. It is difficult to pinpoint exactly what actions or inactions constitute abuse, and the problem remains greatly hidden. State statistics vary widely, as there is no uniform reporting system. Comprehensive national data are not collected.

In the absence of a large-scale, nationwide tracking system, studies of prevalence and incidence conducted in the past few years by investigators have been crucial in helping health care providers understand the magnitude of the problem. Regarding the prevalence of elder abuse, between 1 and 2 million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection, according to the 2002 report, Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America, produced by the National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect (Bonnie & Wallace, 2002). Lachs and Pillemer (2004) estimated the frequency

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of elder abuse from 2 percent to 10 percent, based on various sampling, survey methods, and case definitions. Pillemer and Finkelhor (1988) suggest that regarding elder abuse in domestic settings, 1 in 14 incidents, excluding incidents of self-neglect, come to the attention of authorities. In addition, the ground-breaking 1998 NEAIS conducted by the NCEA estimated that for every case of elder abuse, neglect, exploitation, or self-neglect reported to authorities, about five more cases go unreported. In 2000, a survey of state APS, conducted by the NCEA, determined the number of elder and adult reports received in the most recent year for which data were available. Based on figures from 54 states, the total number of reports was 472,813. In 2003, state long-term care ombudsman programs nationally investigated 20,673 complaints of abuse, gross neglect, and exploitation on behalf of nursing home and board-andcare residents. Among seven types of abuse categories, physical abuse was the most common type reported. 8.4.2.2 Elders: Protected by the Law? According to the NCEA, federal laws on child abuse and domestic violence fund services and shelters for victims, but there is no comparable federal law on elder abuse. The federal Older Americans Act (42 U.S.C. 3001 et seq., as amended) does provide definitions of elder abuse and authorizes the use of federal funds for the NCEA and for certain elder abuse awareness, training, and coordination activities in states and local communities, but does not fund APS or shelters for abused older persons. On February 10, 2003, Senator John Breaux, then-ranking member of the Senate Special Committee on Aging, and Senator Orrin Hatch, then-chairman of the Senate Judiciary Committee, introduced the Elder Justice Act (SB 333) in the Senate. If passed, the new law would, among other things, establish dual Offices of Elder Justice in the U.S. Department of Health and Human Services/Administration on Aging and the U.S. Department of Justice to coordinate elder abuse prevention efforts nationally. It also would require an FBI criminal background check for long-term care nursing assistants and better training for workers in the detection of elder abuse. It would also establish an Office of Adult Protective Services within the U.S. Department of Health and Human Services, Administration for Children and Families. Finally, it would enhance law enforcement response to elder abuse. The bill was referred to the Senate Committee on Finance and no further action has been taken so far at the time of this writing. According to the NCEA, all 50 states and the District of Columbia have enacted legislation authorizing the provision of APS in cases of elder abuse. Generally, these APS laws establish a system for the reporting and investigation of elder abuse and for the provision of social services to help the victim and ameliorate the abuse. In most jurisdictions, these laws pertain to abused adults who

Forensic Nursing

have a disability, vulnerability, or impairment as defined by state law, not just to older persons. These statutes vary widely in the age at or circumstances under which a victim is eligible to receive protective services; the definition of abuse; types of abuse, neglect, and exploitation that are covered; classification of the abuse as criminal or civil; reporting (mandatory or voluntary); investigation responsibility and procedures; and remedies for abuse. Some state APS laws only relate to individuals who reside in the community, whereas other APS laws also include individuals who reside in long-term care facilities. In some states where the APS law only covers individuals who reside in the community, a separate law addresses institutional abuse. Like the APS laws, institutional abuse statutes create a mechanism for reporting, investigating, and addressing incidents of elder abuse that occur in long-term care facilities or other facilities covered under the law. Additionally, all states and the District of Columbia have laws authorizing the Long Term Care Ombudsman Program (LTCOP), which is responsible for advocating on behalf of long-term care facility residents who experience abuse, violations of their rights, or other problems. LTCOPs are mandated in each state as a condition of receiving federal funds under the Older Americans Act. LTCOPs are an integral part of the systemic response to institutional elder abuse. LTCOPs might discover an abusive situation when responding to complaints within a facility and then, if appropriate, make a referral to an APS program, a law enforcement agency, or the agency responsible for licensing and certifying such facilities. Moreover, in some states, the LTCOP actually fulfills the role of APS and has the legal authority to investigate and respond to abuse occurring within long-term care facilities. An increasing number of states are passing laws that provide explicit criminal penalties for various forms of elder abuse. Legislatures are also signaling their intent that elder abuse should be treated as a crime in other ways. For example, some APS laws include a provision stating that elder abuse can be prosecuted criminally, and others define certain acts (e.g., sexual abuse) in the same words or by reference to definitions that are used in the criminal laws. Even if there is not a specific statute or provision authorizing criminal prosecution for elder abuse, a jurisdiction’s basic criminal laws (e.g., battery, assault, theft, fraud, rape, manslaughter, or murder) can be used to prosecute someone who has committed an act of abuse against an older person. Some legislatures have enacted enhanced penalties for certain crimes against older persons. Other state laws might be pertinent in cases involving elder abuse, even though they are not cited in this document. Such laws include those addressing guardianship or conservatorship, durable powers of attorney, and domestic violence or family violence prevention.

Vulnerable Populations

8.4.3 ELDER ABUSE: A REVIEW

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OF THE

LITERATURE

Several years ago, researchers Bonnie Brandl, MSW, senior project specialist for the National Clearinghouse on Abuse in Later Life, and Loree Cook-Daniels, a consultant for the NCEA, set out to document the incidence of domestic violence later in life. They discovered that battered middle-aged women were essentially falling through the cracks when it came to epidemiological data, studies, and services that focused on this underserved vulnerable population. Because they are neither young (domestic violence programs predominantly serve women between the ages of 18 and 45 abused by intimate partners) nor old (most APS address elderly and incompetent victims), mature battered women have no particular support system to which they can turn for assistance. Likewise, although both domestic violence and elder abuse research are presumed to address domestic abuse in later life, researchers often define their target populations in ways that exclude these victims (Brandl & Cook-Daniels, 2002). The researchers define domestic abuse in later life as male and female victims, age 50 and older, abused by someone in a trusted, ongoing relationship such as a spouse or partner, family member, or some caregivers. Brandl and Cook-Daniels reviewed 54 articles published in the literature from 1988 to 2002 pertaining to domestic abuse, excluding studies that focused on younger and older populations of victims. Ten articles studied prevalence and incidence rates of elder abuse in general and domestic violence specifically. Mouton and Espino (1999) found that 4.3 percent of their sample of older women responding to a health survey were currently in an abusive relationship. Harris (1996) found that 5.8 percent of the older couples responding to the survey had experienced domestic violence in the past year. Lachs et al. (1997a, 1997b) examined APS records and found that 1.6 percent of elders had been abused, neglected, or exploited over a nine-year period. Hudson and Carlson (1999) discovered that 6.2 percent of the older adults in their sample admitted to hurting an elder; in another study, the figure was 2 percent (Hudson & Carlson, 1999). Five studies examined abuse occurring at any point in an individual’s lifetime. Hudson and Carlson (1999) found 19.1 percent of women in six counties experienced domestic violence at some point in their lives. Mouton and Espino (1999) and Pittaway and Westhues (1993) discovered that 31.9 percent of men and women had experienced some form of domestic violence. Pillemer and Finklehor (1988) estimated 701,000 to 1,093,560 older Americans were victims of abuse each year. More recently, the U.S. NEAIS estimated that approximately 450,000 older people were being abused in 1996. In their review of the literature, Brandl and CookDaniels (2002) discovered that most of the 28 studies in which a type of abuse in later life was identified involved

more than one type of abuse. For example, 19 percent of victims were abused or neglected in more than one way in Podnieks’s (1992) study and 20 percent in Greenberg, McKibben, and Raymond’s (1990) study. Anetzberger (1997) found that psychological abuse accompanied other types of abuse in 89.7 percent of the sample. Fourteen of the 28 articles Brandl and Cook-Daniels reviewed compared the frequency of different types of abuse in later life. Four studies found neglect was the most prevalent type of abuse: Brown (1989), Lachs et al. (1997a, 1997b), NCEA (1998), and Otiniano, Herrera, and Teasdale (1998). Greenberg et al. (1990), Pillemer and Finkelhor (1988), and Wolf and Pillemer (1997) found that physical abuse was the most prevalent type of abuse. Brandl and Cook-Daniels also reviewed data suggesting that older women can be victims of sexual assault whether they are healthy and married or frail and living in an institution. Nearly all the sexual abuse victims studied were women, and all but one identified perpetrator were male. Mouton and Espino (1999) found that 7 percent of older battered women had been forced to have sexual intercourse with their husbands. In three studies, victims were overwhelmingly impaired: 80 percent of the sample in Burgess, Dowdell, and Prentky (2000) used a wheelchair or were bedridden, and 60 percent had dementia. Teaster, Roberto, Duke, and Myenonghwan (2000) found that 80.9 percent of the sample lived in a nursing home and fewer than one quarter could walk without assistance. Seventy-one percent of the sample in RamseyKlawsnik (1991) were classified as “totally dependent” or functioning “poorly” to “very poorly.” Many of the sexual abuse cases had witnesses: 76.2 percent of the Teaster et al. (2000) sample, and nearly one third of both the Ramsey-Klawsnik (1991) and Burgess et al. (2000) samples. Spouses or intimate partners were the abusers in 29 percent of the Ramsey-Klawsnik (1991) sample. Other sexual abusers were residents of the nursing home (Teaster et al., 2000), sons (Ramsey-Klawsnik, 1991), paid caregivers (Teaster et al., 2000), and brothers (Ramsey-Klawsnik, 1991). Brandl and Cook-Daniels discovered through their 2002 review of the literature that differences might exist among racial and ethnic groups’ definitions of what behaviors constitute elder abuse, according to Anetzberger (1997), Hudson and Carlson (1999), and Moon and Williams (1993). Many individuals are reluctant to report abuse due to ingrained cultural beliefs (Le, 1997; Moon & Benton, 2000; Moon & Williams, 1993; Otiniano, 1998; Sanchez, 1999; Tomita, 1999). Reasons cited for not reporting abuse included shame, embarrassment, not wanting to create conflict in the family, and protecting the community. Moon and Williams (1993) and Sanchez (1999) discovered that some victims preferred to talk to relatives rather than to health care, mental health, or law enforcement professionals. Family members are often the abusers in numerous

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cases of abuse in later life, Brandl and Cook-Daniels discovered (Brownell, Berman, & Salamone, 1999; Godkin, Wolf, & Pillemer, 1989; Lithwick, Beaulieu, Gravel, & Straka, 1999; Otiniano, Herrera, & Teasdale, 1998; Pillemer & Finkelhor, 1988; Podnieks, 1992a, 1992b; Ramsey-Klawsnik, 1991; Vinton, 1992; Vladescu, 1999). The abuser can be an adult child (Brownell et al., 1999; Lachs et al., 1997a, 1997b; Otiniano et al., 1998; Vladescu, 1999; Wolf & Pillemer, 1997), or a spouse (Pillemer & Finkelhor, 1988; Podnieks, 1992a, 1992b). Seaver (1996) and Vinton (1992) found that 58 percent to 95 percent of older women were abused by spouses. Teaster et al. (2000) suggest that other facility residents perpetrated the majority of sexual assaults in institutions. Sometimes, the spouses are beating up on each other; Crichton, Bond, Harvey, and Ristock (1999) found more husbands abusing wives, whereas Pillemer and Finkelhor (1988) found wives reported having used physical aggression against their husbands more than vice versa. Pillemer and Finkelhor also found that 6 percent of men abused by wives were injured versus 57 percent of women abused by husbands. Crichton et al. (1999), Greenberg et al. (1990), Pillemer and Finkelhor (1988), Wolf and Pillemer (1997), and Vinton (1992) suggested that grown sons were more abusive than grown daughters. Ramsey-Klawsnik (1991) found that some adult sons also sexually abused their mothers. Brandl and Cook-Daniels, in undertaking this review of the literature, looked for causation and found several emerging themes. Several studies pointed to power struggles as influencing risk for abuse (Harris, 1996; Pillemer & Finkelhor, 1988). Contrary to what is presumed, a few studies indicated that aggravated caregivers do not work out their frustrations on their vulnerable charges (Phillips, Torres de Ardon, & Briones, 2000; Pillemer & Finkelhor, 1988; Reis & Nahmiash, 1998). However, the literature does support that the abuser is dependent on the victim in some way (Godkin et al., 1989; Pillemer & Finkelhor, 1988; Seaver, 1996; Wolf & Pillemer, 1997). Brandl and CookDaniels (2002) write, “Current thinking about intergenerational cycles of abuse suggests that child abuse victims may retaliate against their aging parents when they become adults. Currently, not enough research exists to support or rule out this idea.” They cite two studies that indicate intergenerational transmission of violence is not an inevitable process but might be a factor in some cases: Korbin, Anetzberger, and Austin (1995) and Podnieks (1992a, 1992b). Many abusers suffer from some sort of impairment, including substance abuse, mental illness, depression, or cognitive impairments (Brownell et al., 1999; Cohen, Llorente, & Eisdorfer, 1998; Godkin et al., 1989; Greenberg et al., 1990; Pillemer & Finkelhor, 1988; Reis & Nahmiash, 1997, 1998; Seaver, 1996). Regarding incidence rates of intervention, it is clear from the literature that many older domestic abuse victims

Forensic Nursing

do not seek assistance from health care providers or law enforcement (Brownell et al., 1999; Phillips et al., 2000), and many might not reveal the abuse at all (Podnieks, 1992a, 1992b). Many victims do not see themselves as being victimized, suggests Phillips et al. (2000). Elder mistreatment is a widespread societal issue that often flies under the radar of health care providers and law enforcement professionals; however, in recent years, a greater awareness of this growing problem has triggered mandated reporting by all health care professionals in most states. Swagerty et al. (1999) defines the word mistreatment as including physical abuse and neglect, psychological abuse, financial exploitation, and violation of rights. Poor health, physical or cognitive impairment, alcohol abuse, and a history of domestic violence are some of the risk factors for elder mistreatment. Diagnosis of elder mistreatment depends on acquiring a detailed history from the patient and the caregiver. It also involves performing a comprehensive physical examination. Only through awareness, a healthy suspicion, and the performance of certain procedures are physicians able to detect elder mistreatment. Once it is suspected, elder mistreatment should be reported to APS. It is estimated that more than 2 million older adults are mistreated each year in the United States. Elder abuse first gained attention about 20 years ago, when the term granny battering first appeared in a British medical journal (Burston, 1975). Since then, elder abuse has become a significant global issue. Although this newfound heightened awareness has followed a growing awareness of child and spousal abuse, because of differing definitions, poor detection, and underreporting, the extent of elder mistreatment is unknown. Published studies estimate that the prevalence of elder mistreatment ranges from 1 percent to 5 percent (Kurrle, Sadler, Lockwood, & Cameron, 1997). Although estimates of the prevalence of elder abuse in the United States have ranged from about 4 to 10 percent of the population 65 years and older, Wolf (1996) says there has been only one community-based study. A study of 2,020 elderly persons in Boston established an overall prevalence of 3.2 percent, which subdivided into 2.2 percent physical abuse, 1.1 percent verbal abuse, and 0.4 percent neglect (Pillemer & Finkelhor, 1988). Spouse abuse (58 percent) was more prevalent than abuse by adult children (24 percent), the proportion of victims was roughly equally divided between males and females, and economic status and age were not related to the risk of abuse. This survey, to which the category of financial abuse was added, was repeated in Canada. Four percent of Canadian elders able to respond on the telephone were found to have recently experienced one or more forms of mistreatment. Again, the rates for men and women were about equal, but financial abuse was more prevalent than physical abuse, verbal aggression, or neglect. As a means for general comparison, a British study, which combined the aforementioned Boston and

Vulnerable Populations

Canadian survey forms, and added several questions, found prevalence of physical abuse of 2 percent, verbal abuse of 5 percent, and financial abuse of 2 percent (Ogg & Bennett, 1992). Although studies of elder abuse in the medical literature appear to be numerous, in a white paper published in the medical journal The Lancet Mark S. Lachs, co-chief of the Division of Geriatrics and Gerontology at the Weill Cornell Medical College in New York City, and Karl Pillemer, professor of human development in the College of Human Ecology at Cornell University, examined the lack of quality research concerning the physical and mental abuse of elderly persons (Lachs & Pillemer, 2004). Restricting their review of what data exists to domestic abuse, they highlight two startling statistics: The rate of elder abuse is probably between 2 percent and 10 percent, and people who have been mistreated are more than three times more likely to die within three years compared with those not abused, even when corrected for comorbidities and other confounding factors. “This vastly unrecognized and under-treated problem compromises the quality of life for millions of older people worldwide,” Pillemer says. “A busy physician, who might see 20 to 40 elderly patients a day, might encounter a case of possible elder abuse every day, but because of a lack of time, resources, and a general lack of recognition of the problem, many cases go undetected and untreated, putting our elderly at heightened risk of physical and mental harm, and even death.” The researchers also discussed possible approaches for screening programs to identify elder abuse, but stated that clinicians’ awareness of the phenomenon is more of a priority to enhance the detection of abuse. They also highlighted the difficulties of accurate diagnosis given the high risk of false positive and false negative judgments. They placed emphasis on the importance of a multidisciplinary approach, with a definite role for health care professionals, including physicians, nurses, social workers, advocates, and members of law enforcement. Lachs comments: Although there are gaps in knowledge with respect to the clinical manifestations and treatment of elder abuse, they should not prevent clinicians from taking an active role in identification and management. Family violence directly affects quality of life, and removal of a patient from an abusive situation is one of the most gratifying experiences for physicians and other health care professionals. Despite the need for more data on interventions, a reasonable approach is a multidisciplinary one, specifically tailored to the situation, ideally involving multiple team members with varied expertise (the model used in other geriatric syndromes). Future research should focus on the creation of clinically useful screening techniques and evidencebased assessments of replicable interventions.

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Lachs and Pillemer assert that elder abuse directly affects quality of life, and helping patients resolve an abusive situation is one of the most gratifying experiences for physicians and other health care professionals. Shields, Hunsaker, and Hunsaker (2004) conducted a 10-year (1992–2001) retrospective case review of morbidity and mortality among individuals age 60 years and older at a state medical examiner’s office serving a major metropolitan region in Kentucky and Indiana. The researchers examined medico-legal autopsies and examinations of living subjects pursuant to a clinical forensic medicine program. They examined 74 postmortem cases in which 52 deaths were attributed to a homicidal act, with 22 deaths that were suspicious for neglect. Of the 22 living victims of elder abuse and neglect, 19 cases constituted physical or sexual assault, and three individuals suffered from neglect. Jones, Veenstra, Seamon, and Kohmer (1997) sought to determine the perceived magnitude of elder mistreatment, physician awareness of applicable state laws, and the barriers to reporting suspected cases. They surveyed a random sample of 3,000 members of the ACEP; survey questions included practice characteristics, number and type of suspected cases of elder mistreatment seen in the ED, the number of cases actually reported, and reasons for not reporting abuse. Physicians were also asked about the availability of elder-mistreatment protocols and their familiarity with local laws and reporting requirements. The researchers received 705 completed surveys, for a response rate of 24 percent. Most physicians (52 percent) described elder mistreatment as prevalent but less so than spouse or child abuse. The respondents had evaluated an average of 93 suspected cases of elder mistreatment in the preceding 12 months; approximately 50 percent were reported. Only 31 percent of emergency physicians reported having a written protocol for the reporting of elder mistreatment, and physicians were generally not familiar with applicable state laws. Twenty-five percent were able to recall educational content pertaining to elder mistreatment during their emergency medicine residencies. Most physicians were not certain or did not believe that clear-cut medical definitions of elder abuse or neglect exist (74 percent); that emergency physicians can accurately identify cases of mistreatment (58 percent); or that their states had sufficient resources to meet the needs of victims (92 percent). The researchers concluded that practicing emergency physicians are not confident in identifying or reporting geriatric victims of abuse or neglect. This lack of confidence might reflect inadequacies of training, research, and continuing education with regard to mistreatment of older people. Comijs et al. (1998) endeavored to assess the prevalence and the consequences of chronic verbal aggression, physical aggression, financial mistreatment, and neglect in a community-based sample, as well as to investigate

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the circumstances that led to the abuse and the ways in which the victims handled the problem. Prevalence was assessed in a population-based sample of 1,797 older people living independently in Amsterdam. In a follow-up study one year later, the victims were questioned again about the background and consequences of the abuse. The one-year prevalence of elder abuse was 5.6 percent, and the prevalence of the various types of elder abuse was as follows: verbal aggression, 3.2 percent; physical aggression, 1.2 percent; financial mistreatment, 1.4 percent; and neglect, 0.2 percent. Most victims reported emotional reactions immediately after the abuse. Seven of 36 victims experienced physical or financial damage as a consequence of the abuse, and more than 70 percent of the victims were able to stop the abuse, either by themselves or with the help of others. The researchers concluded that elder abuse is more widely spread if not only close relatives or people with whom the older person lives are considered as possible perpetrators, but other familiar and trusted people are considered as well. Intervention should be focused on the roughly 40 percent of victims who were not able to stop the abuse, they stated. With constant improvements in socioeconomic conditions, the people of most industrialized nations are living longer. Most elderly individuals lead productive lives within the community. Unfortunately, when elderly individuals suffer from a debilitating disease or injury, society seems ill equipped to care for them. The frailty and social isolation that comes with illness or advanced age renders the elderly more vulnerable to crime. Falzon and Davis (1998) examined the circumstances that surrounded the homicides of individuals 65 years of age or older that occurred in Jefferson County, Alabama over a 15-year span. The researchers conducted a retrospective study of all decedents brought to the Jefferson County Coroner and Medical Examiner Office during the period from 1981 to 1995. Their computer search identified 150 homicide victims who were 65 years or older. In these 150 cases, the causes of death were as follows: gunshot wound, 50 percent; blunt force injuries, 19 percent; knife wounds, 14 percent; and asphyxiation, 10 percent. Younger homicide victims were much less likely to be killed as the result of a direct physical assault; blunt force injuries and asphyxiation combined caused death in only 7 percent of the younger population. Robbery was the most common motive for death in the elderly population, accounting for 37 percent of cases. The most common location for homicides in the elderly population was in their own residence, which accounted for 71 percent of cases. Four elderly homicide victims were shot by the police, and three elderly decedents died as a result of abuse. Kleinschmidt (1997) comments that elder abuse receives less attention than other forms of domestic violence, and fewer than 10 percent of cases are reported. Although all states have legislation addressing elder abuse,

Forensic Nursing

financial support for evaluation and protective services is lacking. Most states have mandatory reporting; however, it might infringe on the autonomy of competent geriatric individuals. Physicians infrequently report elder abuse because they are not familiar with reporting laws, fear offending patients, are concerned with time limitations, and believe they do not have appropriate evaluation skills. Victims often have low self-esteem, blame themselves for the abuse, and do not want to admit their vulnerabilities or betray their families. Kleinschmidt puts forth the caregiver stress hypothesis, which suggests abuse stems from caregiver stress and resentment resulting from chronic care of dependent geriatric patients, as a misconception. Abuse is actually better correlated with the emotional and financial dependence of the caregivers on the geriatric victims. Older patients are most commonly abused by the people with whom they live. Older men and women have similar per-capita abuse rates. Assessment and management should be supportive without assigning blame and should focus on both the patient and the caregiver. Patients in immediate danger should be hospitalized or placed in emergency shelters. Suspected abuse should be reported directly to the appropriate state agency, which can provide a thorough long-term assessment. Although elder mistreatment is suspected to be life threatening in some instances, little is known about the survival of elderly persons who have been mistreated. Lachs et al. (1998) endeavored to estimate the independent contribution of reported elder abuse and neglect to allcause mortality in an observational cohort of communitydwelling older adults. The sample included 2,812 community-dwelling adults who were older than 65 years in 1982, a subset of whom were referred to protective services for the elderly. The researchers reported that in the first nine years after cohort inception, 176 cohort members were seen by elderly protective services for verified allegations; 10 (5.7 percent) of these were for abuse, 30 (17 percent) for neglect, 8 (4.5 percent) for exploitation, and 128 (72.7 percent) for self-neglect. At the end of a 13-year followup period from cohort inception, cohort members seen for elder mistreatment at any time during the follow-up had poorer survival (9 percent) than either those seen for selfneglect (17 percent) or other noninvestigated cohort members (40 percent). In a pooled logistic regression that adjusted for demographic characteristics, chronic diseases, functional status, social networks, cognitive status, and depressive symptomatology, the researchers found that risk of death remained elevated for cohort members experiencing either elder mistreatment or self-neglect, when compared with other members of the cohort. Lachs et al. (1997a, 1997b) wanted to determine longitudinal risk factors for elder abuse and neglect. The researchers linked an established cohort of 2,812 community-dwelling older adults with elderly protective service records over a nine-year follow-up period. Protective ser-

Vulnerable Populations

vices saw 184 (6.5 percent) individuals in the cohort for any indication, and 47 cohort members were seen for corroborated elder abuse or neglect, for a samplingadjusted nine-year prevalence of 1.6 percent. In pooled logistic regression, age, race, poverty, functional disability, and cognitive impairment were identified as risk factors for reported elder mistreatment. Additionally, the onset of new cognitive impairment was also associated with elder abuse and neglect. Because the mechanism of elder mistreatment case finding in this study was a social welfare system (protective services), the influence of race and poverty as risk factors is likely to be overestimated due to reporting bias. Lachs et al. (1997a, 1997b) sought to determine the nature and frequency of ED use by victims of physical elder abuse. Community-dwelling victims of abuse were identified through a state elderly protective service program independent of the health care system in a geographic area served by two EDs. The researchers reviewed ED records and abstracted to determine if and how victims used emergency services. During a seven-year period, 182 elderly victims of physical abuse were identified in the catchment area of the study, and 114 (62.6 percent) had been seen in one or both EDs at least once during a fiveyear window surrounding the initial identification of abuse. These 114 individuals accounted for 628 visits (an average of three); 30.6 percent of these visits resulted in a hospital admission. An ordinal system was used that assigned a probability of any single ED visit being referable to abuse; 37.8 percent of subjects had at least one visit categorized as being of high probability, and 66 percent of subjects had at least one visit that resulted in an injury-related chief symptom or ICD-9 discharge diagnosis. Little is known about the epidemiology of APS agency utilization, the state entities charged with assessment and advocacy for disenfranchised older adults. Lachs et al. (2002) sought to determine the prevalence of utilization by older adults and risk factors for APS. The researchers studied a cohort of 2,812 community-dwelling adults who were older than 65 years in 1982. The main outcome measure was referral to the state ombudsman on aging for protective services. Over the 11-year follow-up period, 209 cohort members (7.4 percent) were referred to the ombudsman 302 times as protective service cases, for a community prevalence of 6.4 percent after adjusting for the sampling strategy of the cohort. Self-neglect was the most common indication for referral (73 percent of the cases). Whereas in bivariate analyses a variety of baseline sociodemographic features, functional impairments, medical conditions, and social network factors were associated with APS use, in multivariable analysis only sociodemographic variables remained independent risk factors, including low income, non-White race, and age older than 75 years at cohort inception.

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Lachs, Berkman, and Fulmer (1994) studied a sample of 2,812 community-living men and women in Connecticut who were over age 65 in 1982, and whose cases had been investigated by Connecticut’s State Ombudsman on Aging in 1985 or 1986. The researchers found that 68 (2.4 percent) members of the cohort received investigation. Features at cohort entry significantly associated with investigation in multiple logistic regression included requiring assistance with feeding, being a minority elder, being over age 75 at cohort inception, and having a poor social network as defined by a social network index. The researchers concluded that functional disability, minority status, older age, and poor social networks were associated with investigation for elder mistreatment in this prospective, communitybased population of men and women over the age of 65. Lachs and Fulmer (1993) state that the signs and symptoms of elder abuse and neglect can mimic those of many common chronic medical conditions in elderly persons. They say that a complete assessment for elder abuse and neglect is time-consuming and is best performed as a regimented evaluation that includes separate histories from the patient and suspected party and a clinical assessment that emphasizes function, cognition, and specific aspects of the physical examination. The management of elder abuse and neglect should be multidisciplinary with several key personnel participating. An elderly person in immediate danger should be removed from his or her environment. For less acute cases, a variety of interventions aimed at decreasing the stress of caregiving or ameliorating other family stressors might be appropriate. Most states require that clinicians who suspect elder abuse and neglect report their concerns to a designated authority. There are many gaps in our knowledge about elder abuse and neglect. It is hoped that with the future application of rigorous epidemiologic methodology as has been employed in the study of child abuse, this social ill can be better understood and prevented. Until then, clinicians must integrate their clinical experience and social skills to recognize the problem and provide thoughtful and compassionate intervention. Rosenblatt, Cho, and Durance (1996) sought to characterize elder mistreatment reporting patterns over time and by reporting source with specific focus on physician reporting, and to determine whether demographic or socioeconomic factors influenced the reporting of elder abuse in Michigan between 1989 and 1993 and whether these factors affected physician reporting rates. A total of 27,371 cases of possible abuse were reported, with 17,238 in persons older than age 65. Physicians reported only 2 percent of cases, and physician reporting rates did not increase over the five-year period. Physician reporting rates were highest in small counties with low physicianto-population ratios. There was a high percentage of primary care physicians in these counties. Forty-seven percent of all reported cases were substantiated. There was

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no difference in substantiation rate for physician-reported cases compared with other professional reporting sources. The researchers concluded that increasing physician awareness of the problem of elder mistreatment and providing physicians with the tools to screen for mistreatment should increase the number of cases that are reported to the agencies responsible for assisting mistreated older people. Akaza et al. (2003) examined the elder abuse cases that occurred in Gifu Prefecture, Japan between 1990 and 2000. The researchers conducted a retrospective study of all the cases in which the victim was 65 years or older and autopsied in the Department of Legal Medicine at Gifu University School of Medicine. Fifteen victims were classified as elder abuse victims: five men and 10 women. The victims ranged in age from 66 to 87 years (average age = 74.5 years). The types of abuse were as follows: physical abuse, 13 cases; emotional abuse, five cases; neglect, four cases; and financial abuse, three cases. In eight cases, the victims were subjected to two or more types of abuse. The cause of death of the victims varied with the type of abuse. In the physical abuse cases, subdural hemorrhage was the most common cause, followed by other violence-related deaths and hypothermia. In the neglect cases, the victims died of either starvation or suffocation after the aspiration of food into the airway. In the domestic abuse cases, one of the victim’s sons was the most common perpetrator, and little or no income was considered to be a risk factor for perpetrators. In the neglect cases, dementia and difficulty in performing activities of daily living were considered to be risk factors for victims, in addition to living in social isolation. Kahan and Paris (2003) state that elderly men and women of all socioeconomic and ethnic backgrounds are vulnerable to mistreatment, and most often it goes undetected. For many elderly victims of abuse, the hospital is the only potential site for outside contact and support. An elder abuse program has been created at Mount Sinai Hospital in New York City, and funding was granted to assist victims with compensation claims, provide counsel and advocacy for victims, and provide support via ongoing telephone contact and referrals to community agencies. Simultaneously, hospital-wide educational seminars and rounds have provided the staff and students with information concerning detection of abuse and neglect. Over a two-year period, 182 cases were identified and assessed. More than 50 percent of these cases involved patients with a diagnosis of memory impairment. Five percent of the cases involved a long history of domestic violence. In most cases a family member was identified as the abuser, and in a majority of instances the victim either denied the suspected abuse or tried to rationalize the abuser’s behavior. Patients were afraid of reporting abuse or changing their situation, despite being informed of possible resources. To combat this escalating problem in our grow-

Forensic Nursing

ing elderly population, interdisciplinary collaboration between physicians and social workers is often crucial. Communication via the medical record can be key to monitoring patients in the community. There also needs to be ongoing education of all hospital staff in an effort to continually promote awareness of this problem. Mosqueda, Burnight, Liao, and Kemp (2004) described the development and operation of a new model for integration of medical and social services. The Vulnerable Adult Specialist Team (VAST) provides APS and criminal justice agencies with access to medical experts who examine medical and psychological injuries of elder abuse victims. They conducted a retrospective, descriptive analysis that included community-dwelling elders and adults with disabilities who were reported for mistreatment and referred to VAST. The researchers found that most cases came from APS for mental status and physical examination for evidence of abuse. Cases referred to a medical response team (269) were significantly different from cases that were not referred (9,505). Ninety-seven percent of those who referred cases to VAST indicated that the team was helpful in confirming abuse, documenting impaired capacity, reviewing medications and medical conditions, facilitating the conservatorship process, persuading the client or family to take action, and supporting the need for law enforcement involvement. As a result, VAST has become institutionalized in that county. Amenable to replication, medical response teams for elder abuse might be useful in other counties across the nation.

8.4.4 AGING: A WOMEN’S ISSUE “Aging is a women’s issue,” declared the International Longevity Center’s current annual report. Among older women, 40 percent live alone and 20 percent live below the poverty line. Older women suffer the most elder abuse and make up more than 80 percent of the nursing home population (Jones, 2004). In a 1992 forum sponsored by the American Association of Retired Persons (AARP), a study was presented on abused elders and older battered women. It reported that although there is evidence that spouse or partner abuse might constitute a large portion of all elder abuse, older women abused by their husbands or partners might be falling through the cracks in both the elder abuse and domestic violence communities. The forum assembled a body of representatives of these communities to exchange information, begin a dialogue, and identify initial recommendations about how to better meet the needs of older battered women. Researchers, advocates, service providers, and medical and legal professionals from the fields of elder abuse and domestic violence participated. Prior to the forum, AARP asked battered women to write about their experiences with abuse and with seeking help. Within a month of the request, more than 500 letters arrived from women who wanted to tell

Vulnerable Populations

their stories in the hope their experiences could help others. Some women were in their 80s and had suffered verbal, physical, and mental abuse for 35, 40, or 50 years. Common threads emerging from these letters included the following: •

•

•

•

• •

The women described years of silent suffering, as many said this was the first time they had ever told anyone of the abuse. Many women were isolated from family and friends as a result of the abuse or of trying to keep the abuse secret. Many women described examples of extreme physical violence, such as being pushed, hit, and even shoved down flights of stairs, suffering fractures, dislocated joints, and deep muscle bruises that took weeks to heal. Almost all of the women wrote about emotional abuse, describing name calling, degrading accusations, and constant verbal battering. Alcohol abuse was a very frequent companion to violent behavior. Many described seeking help from professionals, clergy, and the police, only to be told they must have done something wrong to provoke their husbands. Some had received the help they needed from local services; however, many more had not.

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• • •

•

To enhance protective services, forum participants recommended that communities do the following: •

•

•

• •

The AARP forum attendees agreed that a paucity of information about the over-50 age group makes improved research among the first among steps to link the elder abuse and battered women’s communities. Experts said some questions to be addressed include these: • • •

• •

•

What are the specific risk factors for battering in later years? What roles are played by physical dependency, substance abuse, and other observed phenomena? How often is abuse triggered by age-related events such as retirement or illness? What are the barriers in service systems that prevent older women from seeking and receiving help? What roles do ethnicity, race, and culture play in the way people perceive the problem, seek services, and make decisions?

Ensure that appropriate, accessible, and safe shelters are available that take into account the needs of older women, with special attention to rural communities. Programs should be designed and operated to be multicultural and multilingual. Provide cross-training, coordination, and coalition-building between the elder abuse and domestic violence communities. Sensitize all medical and legal professionals, counselors, and religious leaders about sexism, racism, and ageism. Build coalitions to respond to diversity and help empower battered women. Reach out to older women by disseminating information about domestic violence through senior centers and home services, health clinics and physicians, civic associations, and public benefits offices. Conduct outreach to women whose partners are substance abusers or mentally ill. Provide victim advocates and create sister-tosister “buddy” programs between recently battered and formerly battered women.

A gathering of experts at a symposium sponsored by the U.S. Department of Justice in 2000 discussed approaches to addressing domestic violence and sexual assault against older individuals. Bonnie Brandl, program director of the National Clearinghouse on Abuse in Later Life at the Wisconsin Coalition Against Domestic Violence, noted several factors that are important for effectively identifying and responding to the needs of older victims of abuse or assault: •

The experts who convened at the AARP forum concurred that improving the legal response to a complaint of abuse is another important component in stopping abuse and preventing further incidents, including these actions:

Strengthening abuse laws to cover all abusing partners Educating judges, police, and other legal personnel about the problem Increasing access to affordable legal services through specially trained nonlawyers and developing more user-friendly information about the court system Creating a national registry of abusers

Documenting the number of older people experiencing abuse or assault and documenting the types of services needed is important when developing services or building a case for funding. Brandl suggests collecting information

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•

•

• •

from a variety of sources, including APS, aging programs, and domestic violence programs. A multidisciplinary approach to problem exploration, service design and delivery, and fundraising is more effective than organizing a single entity to do it all. This collaborative approach, although difficult in the beginning, is more likely to sustain the effort over the long term because it allows each organization to contribute based on its recognized strengths. Participants in a collaboration should take time to develop a common language and clear definitions of terms so that all participants understand the values, principles, governance, and operating structures that direct the provision of services. The collaborative environment should allow for honest, up-front discussions about inevitable issues of turf, ego, and control. To get through this difficult time in collaboration building, it is critical that relationships of trust and respect be established early in the process. One way to develop these relationships, Brandl says, is by sharing quality information with each other, both in terms of organizational limitations and strengths.

Using the development of her organization as an example, Brandl noted there were several struggles among various entities in the early stages. These struggles often resulted from the fact that most organizations that were being asked to collaborate were already overwhelmed by the demand for services and yet were underfunded. Brandl recalled the initial response from many providers to a call to focus on older victims was, “We don’t do that work . . . we see our population as 18 to 40 years of age and we’re having a hard time even keeping up with that population. We can’t begin to think about how we’d start working with older victims.”

8.4.5 THE 1998 REPORT ON ELDER ABUSE THAT SHOCKED A NATION Although not completely definitive by its own admission, the NEAIS of 1998 is one of the most comprehensive studies of elder abuse and neglect, and the source of a shocking finding that 450,000 elderly persons in domestic settings were abused or neglected in 1996. The NEAIS was conducted by the NCEA at the American Public Human Services Association. It gathered data on domestic elder abuse, neglect, and self-neglect through a nationally representative sample of 20 counties, collecting data from two sources: reports from the local APS agency responsible for receiving and investigating reports in each county, and reports from approximately 1,100 “sentinels,” or spe-

cially trained individuals in a variety of community agencies having frequent contact with the elderly. Many sentinels were mandatory or voluntary reporters of elder abuse, as defined by state laws. The study established the following definitions: •

• • •

•

•

•

Physical abuse was defined as the use of physical force that could result in bodily injury, physical pain, or impairment. Physical punishments of any kind were examples of physical abuse. Sexual abuse was defined as nonconsensual sexual contact of any kind with an elderly person. Emotional or psychological abuse was defined as the infliction of anguish, pain, or distress. Financial or material exploitation was defined as the illegal or improper use of an elder’s funds, property, or assets. Abandonment was defined as the desertion of an elderly person by an individual who had physical custody or otherwise had assumed responsibility for providing care for an elder or physical custody of an elder. Neglect was defined as the refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Self-neglect was characterized as the behaviors of an elderly person that threaten his or her own health or safety. The definition of self-neglect excludes a situation in which a mentally competent older person (who understands the consequences of his or her decisions) makes a conscious and voluntary decision to engage in acts that threaten his or her health or safety.

The NEAIS estimated that a total of 449,924 elderly persons aged 60 and older experienced abuse or neglect in domestic settings in 1996. Of this total, 70,942 (16 percent) were reported to and substantiated by APS agencies, but the remaining 378,982 (84 percent) were not reported to APS. From these figures, one can conclude that more than five times as many new incidents of abuse and neglect were unreported than those that were reported to and substantiated by APS agencies in 1996. Of 236,479 reports of abuse, neglect, and self-neglect to APS in 1996, 48.7 percent, or 115,110 reports, were substantiated after investigation, 39.3 percent were unsubstantiated, and 8.2 percent were still under investigation at the end of 1996. The remaining 3.8 percent of reports had other outcomes (e.g., suspected victim died, could not be located, or had moved away). Of the 115,110 substantiated reports in 1996 for which information was available, 61.6 percent (70,942) were reports of incidents in which other people maltreated elders, and the remaining 38.4 percent (44,168) were incidents of self-neglecting elders. Of the 70,942 unduplicated substantiated reports of elder abuse attribut-

Vulnerable Populations

able to perpetrators (which excludes self-neglect), the most common types were: neglect (34,525), emotional or psychological abuse (25,142), financial exploitation (21,427), and physical abuse (18,144). Whereas the substantiation rate for all types of investigations of elder abuse combined was 48.7 percent, the substantiation rates for different types of maltreatment varied as follows: physical abuse, 61.9 percent; abandonment, 56 percent; emotional or psychological abuse, 54.1 percent; financial abuse, 44.5 percent; and neglect, 41 percent. A wide variety of reporters of domestic elder abuse were found in the 70,942 substantiated reports of abuse and neglect. The most frequent reporters were family members, who were responsible for 20 percent of all reports, followed by hospitals (17.3 percent), and law enforcement (11.3 percent). In-home service providers, friends or neighbors, and health care providers each made between 8 percent and 10 percent of total reports. Out-ofhome service providers, banks, public health departments, and other reporters were responsible for the remaining reports. Hospitals (19.8 percent) and friends or neighbors (19.1 percent) were the most frequent reporters of substantiated reports of self-neglect in 1996. Law enforcement, in-home service providers, and health care providers each made 12 percent of total reports. Out-of-home providers, family members, banks, the victims themselves, and others made the remaining reports. The report examined the age of victims of different types of abuse reported to APS. The oldest elders (those over 80 years of age), who made up about 19 percent of the U.S. elderly population in 1996, were far more likely to be the victims of all categories of abuse, with the exception of abandonment. They accounted for over half the reports of neglect (51.8 percent), and 48 percent of financial or material abuse reports, 43.7 percent of physical abuse reports, and 41.3 percent of emotional or psychological abuse reports. In all types of abuse and neglect, elderly victims in the 60 to 64 and 65 to 69 age groups accounted for the smallest percentages. Female elders were more likely to be the victims of all categories of abuse, except for abandonment. Although making up about 58 percent of the total national elderly population in 1996, women were the victims in 76.3 percent of emotional or psychological abuse, 71.4 percent of physical abuse, 63 percent of financial exploitation, and 60 percent of neglect, which was the most frequent type of maltreatment. A majority of the victims of abandonment were men (62.2 percent). The study found that elders who are unable to care for themselves were more likely to suffer from abuse. Approximately one half (47.9 percent) of the substantiated incidents of elder abuse involved elderly persons who were not able to care for themselves, 28.7 percent were somewhat able to do so, and 22.9 percent were able to care for themselves. For the national elderly population as a whole, the federal government estimates that 14 per-

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cent have difficulties with one or more activities of daily living. Approximately six out of 10 substantiated elder abuse victims experienced some degree of confusion (31.6 percent were very confused or disoriented, and 27.9 percent were sometimes confused). This represents a high degree of potential mental impairment among this group of abused elders, particularly when compared with the estimated 10 percent of the total national elderly population suffering with some form of dementia. Overall, men were the perpetrators of abuse and neglect 52.5 percent of the time. Of the substantiated cases of abuse and neglect, men were the most frequent perpetrators for abandonment (83.4 percent), physical abuse (62.6 percent), emotional abuse (60.1 percent), and financial exploitation (59 percent). Only in cases of neglect were women slightly more frequent (52.4 percent) perpetrators than men. The age category with the most perpetrators was the 41 to 59 age group (38.4 percent), followed by those in the 40 years or less group, who were perpetrators in more than one quarter of reports (27.4 percent). About one third of perpetrators (34.3 percent) were elderly persons themselves (60 and older). Perpetrators of financial or material exploitation were particularly younger compared to other types of abuse, with 45.1 percent being 40 or younger and another 39.5 percent being 41 to 59 years old. Eighty-five percent of the perpetrators of financial exploitation were under age 60. Data show that family members were the perpetrators in 89.7 percent of substantiated incidents of domestic elder abuse and neglect. Adult children of elder abuse victims were the most likely perpetrators of substantiated maltreatment (47.3 percent). Spouses represented the second largest group of perpetrators (19.3 percent). Other relatives and grandchildren, at 8.8 percent and 8.6 percent, respectively, were the next largest groups of perpetrators. Nonfamily perpetrators included friends or neighbors (6.2 percent), in-home service providers (2.8 percent), and out-of home service providers (1.4 percent). The report provides details about the relationship of perpetrators to the victims for the different types of maltreatment. Self-neglect was included in the NEAIS and a common definition and signs and symptoms were adopted for it, as with all the specific types of abuse and neglect. Self-neglect is defined as the behaviors of an elderly person that threaten his or her own health or safety. Self-neglect generally manifests itself in an older person’s refusal or failure to provide himself or herself with adequate food, water, clothing, shelter, safety, personal hygiene, and medication. Approximately 65.3 percent of substantiated self-neglecting elders were female, even through women make up 58 percent of the overall elderly population. About 65.1 percent of selfneglecting elders were 75 years or older. The largest proportion of self-neglecting elders were in the oldest age category of 80 and older (44.7 percent), and the proportion decreased in each declining age group, with only 6.3 percent

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of self-neglecting elders being in the 60 to 64 year age group (compared to being 23 percent of the total elderly population). Most (93.3 percent) self-neglecting elders have difficulty caring for themselves. Of these elders, 34.3 percent are not capable of caring for themselves, and 59 percent are somewhat able to care for themselves. Three out of 10 selfneglecting elders (29.9 percent) are very confused or disoriented, and 45.4 percent are sometimes confused. Approximately 75 percent of substantiated self-neglecting elders suffer from some degree of confusion. The following conclusions can be drawn from the NEAIS: •

•

•

•

Domestic elder abuse and neglect is a significant problem. NEAIS research shows that about 450,000 unduplicated elders experienced abuse and neglect in domestic settings in 1996. More than five times as many of these incidents of abuse and neglect were unreported than were reported to and substantiated by APS agencies. When elders who experienced only self-neglect are included with those who were abused and neglected, the number increases to 551,000 unduplicated elder persons in 1996. Almost four times as many of these incidents were unreported than were reported to and substantiated by APS agencies. The NEAIS measured a large and previously unidentified and unreported portion of elder abuse and neglect, and also has learned much about the characteristics of the victims and perpetrators of abuse and neglect. At the same time, it was not possible to identify and report on all previously hidden domestic elder abuse and neglect, including the most isolated elders who do not leave their homes or who rarely come in contact with others in the community. Several of the characteristics of abused and neglected elderly persons are particularly worrisome and challenge health care providers, law enforcement, and social services agencies to intervene: 1. The oldest elders (80 and older) are abused and neglected at two to three times their proportion of the elderly population. 2. Female elders are abused at a higher rate than males. 3. Almost half of substantiated abused and neglected elderly were not physically able to care for themselves. 4. In almost nine out of 10 incidents of domestic elder abuse and neglect, the perpetrator is a family member. Adult children are responsible for almost half of elder abuse and neglect.

5.

6.

7.

Elderly self-neglect also is a problem, as evidenced by about 139,000 unduplicated reports (some of the self-neglecting elderly might also be counted as being abused or neglected). Most victims of self-neglect are unable to care for themselves and are confused. Using precisely developed standard errors, the NEAIS estimates that as many as 688,948 or as few as 210,900 elder persons might have been abused or neglected in domestic settings in 1996. When selfneglecting elders are added, the estimate range is that as many as 787,027 or as few as 314,995 elder persons might have been abused, neglected, or self-neglecting in domestic settings in 1996. Still more of the unidentified and unreported area of the iceberg remains to be revealed, especially instances of abuse and neglect among seriously isolated elderly persons and those with little contact with community organizations.

Most important, the NEAIS documented the existence of a previously unidentified and unreported stratum of elder abuse and neglect, thus advancing the understanding of the “iceberg” theory of elder abuse. The NEAIS estimated that for every abused or neglected elder reported to and substantiated by APS, there are more than five abused or neglected elders that are not reported. The study also documented similar patterns of underreporting of selfneglecting elders. The collective challenge for policymakers, service providers, advocates, researchers, and society as a whole is to utilize this data to help educate those whose purpose it is to assist the elderly.

8.4.6 DETECTION AND MANAGEMENT OF ELDER ABUSE IN THE CLINICAL SETTING In 2000, Sidney Stahl, chief of health care organizations and social institutions at the National Institute on Aging, chaired a workshop sponsored by the U.S. Department of Justice in which experts were seeking answers to the problem of elder abuse. He said that medical issues, not just social issues, can play a key role in the genesis of elder abuse and neglect at home: Although the connections might not be obvious at first glance, underlying ailments that may contribute to these problems include dementia, depression, psychosis, alcoholism, and early cognitive loss. This relatively new understanding highlights the need for medical professionals to work with Adult Protective Services, law enforcement, and other parties to help diagnose and treat elder abuse and neglect. Yet physicians generally have

Vulnerable Populations

done a poor job in this regard. Among other reasons, doctors are unaware of the need, have not been trained to recognize abuse and neglect cases, or fear that such cases will drag them into court or obligate them to provide free services. Lessons can be learned from experts in child abuse, criminal justice, social services, and victim advocacy, in addition to the medical community, that can help overcome these problems.

Health care providers are well positioned to detect and manage elder mistreatment, because they might be the only individuals who regularly see the older adult. They also order the testing, hospital admissions, and support services that are sometimes needed to correct elder mistreatment. Vernon (1995) writes: The geriatrician is well accustomed to compiling a differential diagnosis from nonspecific and puzzling presentations. Delay in seeking medical help, inconsistent or implausible history, examination and laboratory findings, absence of a designated care-giver at presentation and chronic disease disequilibrium in the presence of an adequate care plan all raise the possibility of abuse or neglect. Armed with a greater awareness of abuse and in the familiar setting of a multidisciplinary team, the geriatrician can therefore proceed to evaluate a given presentation for its abusive or neglectful content. Furthermore the alert clinician can readily screen for such issues by routinely asking elderly patients about their perception of personal safety and experience of physical, verbal or psychological abuse or neglect. Such questions logically form part of an expanded social history. Routine clinical practice calls for full physical, neurological and cognitive assessment of a patient.

Gray-Vickery (2004) writes, “In some cases, you may need assessment radar to detect elder abuse. Keep in mind that normal effects of aging, disease pathology, and functional limitations can mask the signs and symptoms. For example, thin aging skin is susceptible to tearing and bruising, but don’t fall into the trap of assuming that skin tears and bruises in an older person are always predictable signs of aging.” Gray-Vickery says that health care providers can learn a lot about a patient’s relationship with his or her caregiver by observing their behavior when together. Is the caregiver’s demeanor calm and reassuring, or threatening? Do they converse or sit in silence? Writes Gray-Vickery, “A subtle tip-off to physical abuse is when a caregiver underreacts or overreacts to findings from the older person’s physical examination. For example, he may refuse to have the patient hospitalized for serious injuries; at the other extreme, he may be extremely anxious to have her admitted.” If abuse or neglect is suspected, Gray-Vickery advises providing an interview environment where the patient can feel safe to talk about his or her situation. “Although you may at some point interview him/her and

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his/her caregiver together to assess their interactions, conduct your initial discussions one-on-one.” To protect the patient against possible retaliation by the caregiver, GrayVickery suggests conducting the interview in a private location. “Remember that a victim may not want to report abuse or her abuser because she feels shame and fears abandonment or retaliation. She may be reluctant to undress because she doesn’t want to reveal her injuries.” GrayVickery suggests approaching the patient with a warm, empathetic manner, and after exchanging pleasantries, the clinician should make a statement that lets the patient know he/she can speak up. “For example, if you note bilateral bruising or other signs of physical abuse, you might say, ‘Injuries like this usually don’t happen by accident. Perhaps someone else was involved.’ Ask her directly about the possibility of abuse. Assure her that you’ll take her seriously and that she’ll be protected from retaliation.” The caregiver should also be interviewed. Once the patient and the caregiver have been questioned, Gray-Vickery suggests considering whether or not the nature of the patient’s injuries is consistent with the patient’s and the caregiver’s stories. “For example, a patient may say that she’s come to the hospital because of flu-like symptoms, but you note untreated bruises and burns over her torso. Or the caregiver may blame suspicious injuries on the older person, saying that ‘She’s clumsy.’” If a patient has dementia or some other cognitive impairment, or when a patient denies suspected abuse, Gray-Vickery advises, “Base your determination of potential abuse on the patient’s physical assessment, your interview with her caregiver, and your assessment of their interactions.” Regarding the documentation of suspected abuse, Gray-Vickery emphasizes that health care providers should document the results of assessment and all the data collected. “Include what she and her caregiver said about her injuries. Identify each speaker and use exact words within quotation marks. ‘Patient states, ‘He kicked me in my head and back’ carries more weight than ‘Patient was allegedly kicked by son.’ Direct quotes help eliminate liability issues because your opinions aren’t included, and they may be invaluable evidence if the case ever goes to court.” Health care providers should document any discrepancy in the patient’s and caregiver’s stories. If the patient says she tripped and fell down a flight of stair and the caregiver says the patient fell out of bed, include both accounts. Use a body map to document the location of all injuries, and identify the type of injuries on a checklist or in a narrative description. Include photographs of the injuries in the medical record, ensuring first that the patient gives informed consent. Most states require nurses to report suspected abuse. Health care providers should follow their facility’s reporting policy if they encounter an older adult in any of the following situations:

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• • •

Detection of evidence of an injury or neglect without a reasonable clinical explanation. The patient complains of abuse. The health care provider believes, based on observation and experience, that the risk of abuse and neglect is high.

Gray-Vickery says: Many facilities have multidisciplinary teams that specialize in handling abuse cases, and all states have statutes on reporting them. Laws differ from state to state, but most states require professionals to report all suspected incidents of elder abuse to officially designated agents. If an older patient has been abused or you suspect imminent risk, initiate a safety plan for her. She and her caregiver may benefit from referrals to social services, counseling services, and legal assistance. She may need court protection, hospital admission, or placement in elder abuse transitional housing known as a “safe house.”

Gray-Vickery adds, “With careful assessment, documentation, and reporting, you can make a critical difference to the welfare of an older person who’s a victim of abuse. And by teaching older people how to avoid abuse, you can target the problem before it becomes a reality.” 8.4.6.1 Red Flags for Abuse Indicators of physical abuse include the following: • •

•

•

•

•

Multiple fractures or injuries in various stages of healing. Bruises clustered together and in regular patterns, especially in unusual locations such as the neck or groin. Lashes from a belt can cause injuries extending over several planes, such as the front, side, and back of the legs. Bilateral bruises or parallel injuries, “control marks,” a sign of forceful restraining. Frequent shaking causes parallel injuries on the upper arms. Injuries to the trunk, abdomen, genitalia, buttocks, and upper thighs, which might signal sexual abuse. Forced sexual activity can cause visible injuries, pain, or itching in the genital region; evidence of STD; fractured teeth; and ecchymosis of the uvula. Injuries around the face, ears, and neck, including tooth fractures and whiplash injuries. (Accidental bruises usually affect the forehead, knees, shins, and elbows; senile purpura marks typically appear on the forearms and backs of the hands.) Burns to the soles, palms, or buttocks or circular cigarette or cigar burns. Being tied up or

•

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•

• • • • • • • • • • • • •

restrained can cause rope burns on the extremities, neck, or torso. Patterned injuries that can give clues to the size and the shape of the object that caused them, such as belt buckles or hands. Sprains or dislocations caused by pulling or pushing. Patchy hair loss, redness, and swelling over the scalp or areas of hemorrhaging just below the scalp line, which can occur with violent hair pulling. A history of frequent visits to the ED or a delay between the time of injury and going to the ED. Repeated falls, fractures, or bruises in various stages of healing, and a verbal report of physical abuse are high-risk indicators of abuse. Withdrawn behavior or flinching when approached. Indicators of neglect include the following: Deterioration of health Dehydration, malnutrition, or cachexia Pressure ulcers or contractures Dirt and odor on the body or clothing Assistive devices missing or in poor repair, such as broken glasses Inappropriate dress Fleas or lice Urine burns Listlessness and fatigue Any indication that the older person was left in an unsafe situation or alone for long periods Poor personal hygiene

Indicators of emotional abuse include the following: • • • • • • • •

Confusion and disorientation Paranoia, depression, or anger Fear of strangers Exhibiting fear in one’s own environment Ambivalence toward caregiver Being quiet when caregiver is present Low self-esteem Hunger for attention and socialization

8.4.6.2 Clinical and Medical Forensics of Elder Abuse Dyer, Connolly and McFeeley (2002) assert, “The medical forensics aspects of elder abuse and neglect are largely unexplored and undocumented. Those who work in the field of elder abuse and neglect believe that the state of medical knowledge and forensic science regarding elder abuse and neglect is approximately equivalent to that of child abuse and neglect three decades ago and domestic violence 10 to 15 years ago.” They explain that there is a

Vulnerable Populations

set of what they call “forensic markers” of elder abuse and neglect, including abrasions, lacerations, bruising, fractures, decubiti, weight loss, dehydration, medication use, burns, cognitive and mental health problems, poor hygiene, and sexual abuse. They add, “Expanding our medical forensic knowledge base is vital to all the myriad ways in which the law is expected to address elder abuse and neglect.” Elder abuse often goes undetected and unreported, which precludes intervention, investigation, and prosecution. It falls within the health care provider’s purview to identify clinical cases of suspected abuse and neglect, document and collect evidence, and in doing so, assist law enforcement and prosecutors in the criminal justice process. The AMA defines physical abuse as an act of violence that can result in pain, injury, impairment, or disease. Neglect is the failure to provide the goods and services necessary for functioning and avoiding harm. Dyer et al. (2002) underscore the health care provider’s role by pointing out that actual abuse is rarely directly observed by medical, legal, or protective-services personnel, so in the absence of eyewitness testimony, the law enforcement and criminal justice communities must depend on evidence to prove the existence of suspected abuse. Although a bruise might resolve and a bone can heal in time, health care providers are in an excellent position to add meaning to such injuries using their medico-legal-related knowledge and skills of observation and documentation. The most extreme cases of abuse—the gunshot wounds or the knife wounds—are obvious, and bite marks or starvation can indicate extreme neglect. However, it is in the cases with subtle presentations, where abuse and neglect are not clear-cut, that health care providers can excel. Dyer et al. (2002) say that because there is no gold standard when it comes to the detection and substantiation of abuse cases, health care workers must rely on these forensic markers. However, Dyer et al. point out, “The difficulty with this approach is that there is often a great overlap among the markers of disease and neglect (and sometimes abuse). Although abuse often is considered to require an overt act, whereas neglect is considered to require an omission, it is sometimes difficult to distinguish between the two.” A more thorough discussion of forensic markers that can help health care providers recognize abuse follows. •

Crane (2002) defines abrasions as superficial injuries involving the outer layer of skin, whereas lacerations are characterized by full-thickness splitting of the skin. Abrasions are caused by movement of the skin over a rough surface; lacerations are the result of blunt force. Malone, Rozario, Gavinski, and Goodwin (1991) say that skin tears are a common type of laceration seen in the elderly; they are defined as a splitting of

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•

•

•

the epidermis from the underlying connective tissue, resulting in a skin flap. Health care providers should be aware of age-related changes in the skin, including the reduction of tensile strength and the increased susceptibility to shearing-force trauma. Knight (1997) suggests that because abrasions retain the pattern of the causative agent better than any other kind of injury, health care providers should document these kinds of injuries very carefully and completely. Skin tears in areas other than the arms and legs, or multiple tears or abrasions could raise suspicion. Abrasions and lacerations are most commonly seen in cases involving physical abuse, or sometimes in cases of caregiver neglect. Bruises are caused by blunt force trauma with concomitant rupture of small blood vessels under the skin. They are most often seen in abuse cases, but can also be the result of caregiver neglect. Bruises occur more frequently and resolve more slowly in the elderly, and can be the source of patterns suggesting the weapon. Bruises can retain the shape of knuckles or fingers, they can present in the form of tramline bruising (parallel marks) indicating injury from a stick, or they can reflect the imprint of cords. The most common locations for nonaccidental bruising are the face and neck, chest wall, abdomen, and buttocks. Fractures are broken bones and include a severing of the bone or a compression of intact bone. Age-related changes in the bones of elderly persons include thinning from osteoporosis or some other disease. Fractures of the wrist, hip, and vertebra are particularly prevalent among the elderly. The resolution of fractures in children has been much more widely studied than the resolution of fractures in the elderly, Dyer et al. (2002) assert. Because 50 percent of nursing home residents fall, injuries from falls alone cannot necessarily increase a health care provider’s index of suspicion. Dentists frequently see physically abused patients with fractured, subluxed, or avulsed teeth or fractures of the mandible and maxilla (Fenton, Bouquot, & Unkel, 2000). A spiral fracture of a large bone with no history of gross injury is diagnostic of abuse, as are fractures with a rotational component (Dyer et al., 2002). A decubitus is the breakdown of skin integrity, resulting in an ulcer. Decubiti are the result of circulatory failure due to pressure; shearing forces cause thrombosis of the microcirculation, resulting in tissue necrosis (Barton & Barton, 1981). Decubiti, divided into four stages,

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•

•

•

can be deep or superficial, and they are usually found over the sacrum, the hip, and the heels. They most often occur in medically ill or cognitively impaired individuals, and nutritional status and incontinence place the elderly at risk for these ulcers. Schor, Selby, and Bertone (1995) say that there is divided thought on whether decubiti are due to illness, neglect, or even abuse. The failure to adhere to the standard of care could be due to institutional, medical, or caregiver neglect. Malnutrition and dehydration. Gerontologists know that with age comes a decrease in the ability to smell and to taste, requisites for a healthy appetite. Poor dentition, dementia, and depression can also contribute to malnutrition. Malnutrition is a common marker of caregiver neglect in institutional settings; Knight (1997) says that more than 40 percent loss of body weight can lead to death. Improper feeding techniques, such as forceful assistance that can lead to choking and aspiration of food or liquids into the lungs, can lead to serious injury or death. Similarly, dehydration is a common marker of caretaker neglect in the elderly. Lowenstein, Crescenzi, Kern, and Steel (1986) found that dehydration is a common reason for visits to the ER by elderly persons. A burn results from tissue injury following exposure to heat above 50 degrees Celsius, according to Knight (1997). Burns are categorized according to the depth of tissue destruction and the percentage of body surface affected. The National Fire Protection Association says that persons over the age of 65 have twice the national average death rate due to burns. Although the association between burns and child abuse has been well documented, the same cannot be said for burns in the elderly. Bowden, Grant, Vogel, and Prasad (1988) found that 70 percent of burn cases presenting at a university-associated burn center were attributed to neglect and abuse. Bird et al. (1998) found that 40 percent of burn cases occurring in individuals 60 and older were due to abuse or neglect. In a paper about forensic nurses, White (2000) recommends that burns be considered a marker for elder neglect. Cognitive and mental health problems. Dyer et al. (2002) write, “Cognitive and mental health disorders are some of the most pervasive and clinically challenging problems of old age.” Dyer and Goins (2000) report that the Texas

•

Elder Abuse and Mistreatment Institute has treated more than 300 abused or neglected elders; the most common mental and cognitive disorders noted are depression, dementia, psychosis, and alcohol abuse. Dementia, in particular, is a prevalent condition in today’s elders. This progressive impairment of memory and other areas of cognition results in an eventually reduced ability to care of oneself. It is often a triggering factor for self-neglect, which in turn makes the individual more vulnerable to mistreatment by others who would prey on them. Hygiene. Dyer et al. (2002) say that although there are no changes in one’s hygiene that occur strictly with age, poor eyesight or other cognitive impairments might make it harder to keep oneself clean. Aravanis et al. (1993), Lachs and Pillemer (1995), and Butler (1999) have suggested that a marked decline in hygiene could be a marker of neglect. Age-related physiological changes in the genital areas have been documented. There is some research to suggest that changes in hygiene habits could indicate sexual abuse. Mickish (1993) categorized sexual abuse as the least perceived, acknowledged, detected, and reported type of elder abuse.

8.4.6.3 Screening for Elder Abuse in the Clinical Setting In 1987, the AMA provided physicians with a tool to help identify elder abuse. It published a position paper on elder mistreatment that proposed a standard definition: “‘Abuse’ shall mean an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Abuse includes intentional infliction of physical or mental injury; sexual abuse; or withholding of necessary food, clothing, and medical care to meet the physical and mental needs of an elderly person by one having the care, custody or responsibility of an elderly person.” In 1993, the AMA published Diagnostic and Treatment Guidelines on Elder Abuse and Neglect, which listed the following questions that health care providers can ask elderly patients: • • • • •

Has anyone at home ever hurt you? Has anyone ever touched you without your consent? Has anyone ever made you do things you didn’t want to do? Has anyone taken anything that was yours without asking? Has anyone ever scolded or threatened you?

Vulnerable Populations

• • • •

Have you ever signed any document that you didn’t understand? Are you afraid of anyone at home? Are you alone a lot? Has anyone ever failed to help you take care of yourself when you needed help?

“We’ve talked a lot about elder abuse (by caregivers, such as nursing home aides), but we have not been willing to admit the prevalence of elder abuse by family members,” commented then-AMA board member Palmer E. Formica at the time of the guidelines’ issuance. In 2000, the U.S. Department of Health and Human Services vowed, as one of its health goals, to ensure that at least 90 percent of the nation’s hospital ERs use written protocols for identifying, treating, and referring victims of domestic abuse. The 1987 AMA position paper explains that elder abuse takes many forms, including physical abuse and neglect, psychological abuse, financial exploitation, and violation of rights. A major obstacle to prevention of and intervention for elder mistreatment is a lack of awareness on the part of health care professionals. Lachs (1994, as cited in AMA, 1987) says that cognitive impairment and the need for assistance with activities of daily living are important risk factors for elder mistreatment. Lachs (1996, as cited in AMA, 1987) adds that caregiver burnout also can lead to elder abuse. Hwalek, Neale, Goodrich, and Quinn (1996) discovered that substance abuse by the caregiver or the patient significantly increases the risk of physical violence and neglect, and that psychological and character pathology in the caregiver and patient are also major risk factors. 8.4.6.4 The Patient History and Physical Examination It is essential that health care providers obtain a comprehensive patient history; however, this is a challenging task due to the presence of cognitive impairment in the older adult, or the elder’s fear of retribution at the hands of the abuser. Elders who have been abused frequently present with somatic complaints. Because mistreatment can sometimes be subtle or confused with other behavior, health care providers should inquire about instances of rough handling, confinement, and verbal or emotional abuse. These confusing incidents might be discovered during the older adult’s routine visits to a health care facility (Swagerty, Takahashi, & Evans, 1999). Essential components of the patient history include the following: • • •

Medical problems and diagnoses Detailed description of home Accurate description of events related to injury or trauma

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• • • •

• • • •

History of prior violence Description of prior injuries and events surrounding them Description of berating, threats, or emotional abuse Improper care of medical problems, untreated injuries, poor hygiene, prolonged periods before presenting for medical attention Depression or other mental illness Extent of confusion or dementia Drug or alcohol abuse Quality and nature of relationships with caregivers (Swagerty, et al., 1999)

If an elder is being cared for by a caretaker, it is generally advisable that the patient be interviewed without the caregiver present. The health care provider should endeavor to piece together an accurate idea of the patient’s daily life, including meals, medication, and social interaction. It is also crucial to ask the patient about the nature and quality of the relationship with the caregiver. If issues of mistreatment are raised, the caregiver should be interviewed as well. The physician must be careful not to overinterpret or to make suggestive comments, especially when the patient is cognitively impaired (Swagerty, et al., 1999). Essential components of the patient physical examination include thorough inspection of the patient’s body for possible signs of mistreatment: • • • •

• •

Head: Traumatic alopecia or other evidence of direct physical violence; poor oral hygiene Skin: Bruises, welts, bite marks, burns, or decubitus ulcers Musculoskeletal: Fractures or signs of previous fractures Neurologic: Cognitive impairment that is a risk factor for mistreatment and influences management decisions regarding competency Genito-rectal: Poor hygiene, inguinal rash, impaction of feces General: Weight loss, dehydration, poor hygiene, unkempt appearance (Swagerty, et al., 1999)

The physical examination is often used as legal evidence of mistreatment, and often dictates the need to perform additional clinical or imaging interventions to confirm any suspicious findings. The presence of dehydration and malnutrition can be established with simple laboratory tests such as a complete blood count and measurement of blood urea nitrogen, creatinine, total protein, and albumin levels. Radiographic studies provide evidence of old and new fractures, although proving that a fracture was caused

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by abuse can be difficult (Swagerty, et al., 1999). Documentation of all findings by health care providers is critical, because it can be entered as evidence in criminal trials or in guardianship hearings. Chain of evidence must be followed, including the collection of physical evidence in cases of suspected sexual or physical abuse. 8.4.6.5 Screening Tools for Elder Abuse There is consensus that elder abuse and neglect are significantly underreported and underidentified, making screening tools vitally important. Dyer et al. (2002) write, “It is essential to screen for elder mistreatment, particularly in older persons who are either unable, due to cognitive impairment, or unwilling, due to fear, to report it.” Jones, Daougherty, Schelbic, and Cunningham (1988) found that 72 percent of elder abuse victims did not complain of the abuse at the time they presented to the ER. In a 1997 survey of ER physicians by Jones and colleagues, 31 percent worked in a department that had elder abuse screening protocols, 33 percent worked in departments without these protocols, and 36 percent were unsure. Fulmer and Birkenhauer (1992) and Mouton and Espino (1999) recommend that screening for elder abuse be a part of the routine health assessment for all older individuals. A number of screening tools for elder abuse exist. The Comprehensive Geriatric Assessment (CGA) is an ideal tool for evaluation of abused or neglected persons, according to Aravanis et al. (1993), Lachs and Pillemer (1995), and Dyer and Goins (2000). The CGA requires obtaining a comprehensive history and physical examination, and the use of validated instruments to quantify measures of psychosocial health and function. Alessi, Struck, and Aronow (1997) found that the CGA has been shown to be effective in at least eight randomized trials. The Elder Assessment Instrument (EAI) was developed in 1981 and includes a checklist for assessing five domains, a summary, a disposition, and a narrative if the examiner chooses to use one. It is used by ED nurses and physicians, and Fulmer and Paveza (2000) demonstrated that the sensitivity and specificity were 71 percent and 93 percent, respectively, when compared with a panel of experts. These are just a few of the screening tools that currently exist. Dyer et al. (2002) report that several regions in the United States have formed multidisciplinary forensics teams that review and respond to suspected cases of elder abuse or neglect. Not only do the teams provide better coordinated intervention and response, but they are developing experience and expertise in providing a more sophisticated forensic analysis than was previously available from nonaffiliated professionals working outside of a team structure. Dyer et al. write, “Because there are so few such teams and because the data are so scarce, multidisciplinary efforts dedicated to addressing elder abuse and neglect should be studied, encouraged, and supported.”

Forensic Nursing

8.4.6.6 Special Considerations for Postmortem Analysis Dyer et al. (2002) assert, “Many of the same potential markers for elder abuse and neglect in the context of living persons also apply in a post-mortem evaluation but are limited by inability to interview the patient and evaluate such things as mental status and capacity.” Dyer et al. say that the external examination by a forensic pathologist should include evaluation of the person’s state of nutrition and documentation of cleanliness. He writes, “A body with crusted fecal material and secretions of dirt in skin creases, which is clad in very clean or newappearing clothing should suggest an attempt to disguise poor hygiene and living conditions.” Decubiti should be documented, as should bruising, skin lacerations, and fractures. The examiner should provide a detailed description of the size, color, extent, and location of these injuries in the medico-legal record. Patterned bruising or abrasions might indicate the object(s) causing the injury; for example, a line of circular bruises could represent finger marks. Injuries suggestive of defensive maneuvering could also prompt suspicions (Brogdon, 1998). Internal examination could provide additional evidence of markers of abuse or neglect. Organ examination can provide the state of nutrition and hydration, as well as the presence of natural disease. Inspection of the external and internal genitalia should be done to evaluate for sexual assault. “Post-mortem examination in many cases provides less information than would a complete physical examination in a living person,” assert Dyer et al. (2002). “On the other hand, some post-mortem examination procedures yield more information than physical examination and laboratory testing of a living patient.”

8.4.7 ELDER ABUSE

IN THE

HOME SETTING

In a 2000 OVC of the U.S. Department of Justice symposium, experts gathered to discuss the problem of elder abuse in the home. According to a report coming out of this event: Despite the fact that elder abuse and neglect in the home is an increasing phenomenon, only about one in five incidents gets reported and efforts to identify and address situations of abuse are often ill informed, disjointed, lacking in resources, and ineffective. This is partly due to the complexity of the issue; elder abuse in the home is often carried out by family members, which not only inverts societal expectations of familial care but also makes it difficult for investigators to detect and determine the extent of the abuse. Long-term patterns of domestic abuse make it less likely that an older person will seek help, the isolation of the victim is more easily enforced by the abuser when the older person lives at home, and consideration of civil liberties makes the job of the investigator who suspects elder abuse in the home an extremely difficult one.

Vulnerable Populations

Until recently there has been minimal funding directed toward educating professionals and the public on the issue of elder abuse in the home, and laws concerning the rights of the abused and prosecution of the abuser vary considerably from state to state. Numerous agencies and individuals who work with older persons are attempting to rectify this situation, and panelists presented different ways of understanding, responding to, and addressing the problem. Speaking at the symposium, California resident Joyce Speakman related a personal experience that highlighted the importance of the issue and the suffering that can be caused by elder abuse by family members. Speakman said that her mother, Hazel Speakman, who died in August 1998 at the age of 78, endured years of physical and emotional abuse and neglect in her own home at the hands of a relative. Five years before her mother’s death, Speakman knew nothing about elder abuse and thought her suspicions were disloyal to the family, but she eventually contacted the county’s APS agency. She found the agency representatives to be committed, compassionate, and eager to get at the truth, but each labored under the same limitations: Her sister prohibited APS workers from interviewing her mother and thus they concluded that no determination of elder abuse could be made. In her quest to discover the extent of her mother’s abuse, Speakman involved numerous other agencies and individuals, including a nonprofit case worker who was sympathetic but inexperienced, a church pastor who was conciliatory but ineffectual, and the local mental health system, which attempted to address, although only temporarily, her sister’s mental health disorders. No one suggested involving the police, and when Speakman contacted them after her mother’s death, they reported they would not investigate the prior circumstances of a dead victim. Medical records obtained after her death revealed that, among other things, Hazel Speakman had suffered 12 serious falls and numerous broken ribs. Although Speakman realizes that her relative’s efforts to isolate her mother made the APS agency’s original investigation difficult, she was disillusioned by their conclusions and believes a more in-depth understanding of the dynamics of elder abuse and risk factors for potential abusers would have been helpful. The National Association of Adult Protective Service Administrators (NAAPSA) provides the system that receives reports of elder and adult abuse, investigates complaints, and attempts to ameliorate abuse. It operates under a mandate to protect safety, health, and civil liberties, and the social services it provides can include linkage with law enforcement, and legal, medical, transportation, housing, and psychiatric services. APS caseworkers must make critical, life-changing decisions in complex situations, which can include matters of financial concern, legal issues, mental health concerns, issues regarding physical and sexual assault, and a wide variety of family situations.

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Consequently, agency administrators attempt to develop multidisciplinary teams that bring together representatives from the mental health system, law enforcement, victim services, domestic violence, and others. In 1999, NAAPSA conducted a survey of state APS programs. Analysis of the survey data indicated that APS agencies in 48 jurisdictions, including the District of Columbia and Guam, had received 443,000 complaints of abuse, neglect, and exploitation, and that a majority of these incidents had occurred in the victim’s home. As research indicates that one of every five cases of elder abuse is reported, there might be millions of older people who are abused, neglected, or exploited. Despite this overwhelming need, APS is resource-poor, funded primarily by state and local dollars. The only federal funding available for elder abuse services continues to be directed solely at prevention, and has remained stable at $4 million to $5 million per year. In comparison, NAAPSA has determined that domestic violence services receive approximately $200 million in federal funding, and those addressing problems of child abuse receive about $4 billion. APS systems differ significantly from state to state, but there is no federal elder abuse statute. At the symposium, Bonnie Brandl, program director of the National Clearinghouse on Abuse in Later Life, Wisconsin Coalition Against Domestic Violence, discussed elder abuse in the context of domestic violence. Although many people find the actions of those who abuse older persons to be incomprehensible, it is important to understand that both abusers and those who seek to intervene on the behalf of the abused operate within particular belief systems. Brandl said that to understand what type of tactics abusers use and how victims are affected by abuse, belief systems on both sides of the problem must be examined. She noted that family members who abuse other family members believe they are entitled to use whatever tactic they want to dominate or punish their victims, including physical abuse, sexual abuse, financial exploitation, isolation from other family members, the withholding of medication, the abuse of beloved pets, the ridiculing of spiritual beliefs, and a range of other behaviors and threats. Some of the belief systems subscribed to by abuse prevention and treatment professionals are more complex. They include the following theories about elder abuse: •

•

•

It is a problem of caregiver stress, and should involve social services rather than law enforcement. What happens within the family is a private matter, and law enforcement should make every attempt to fix the situation without making arrests. Some abusive situations are not particularly dangerous, and law enforcement officers should

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•

be discouraged from bringing abusers who might be older or disabled into a system that has no place for them. Most elder abuse victims will not access services anyway, so money and effort spent supplying them is wasted.

These belief systems do not consider the victim’s safety to be of paramount importance. As a result, victims are caught between their abuser and a community that does not want to think of this as an issue of power and control, or is not looking to make an arrest, or is not developing services for the abused. It is necessary to understand what barriers the victims face when the system fails them, said Brandl, and to use victim input to inform what types of programs are developed. “A lot of us measure success by whether we close cases or get funding or start a new program,” she said, “but I would encourage you to measure success based on whether victims are safer as a result of the intervention options you create in your state.” Also at the symposium, Dr. Holly Ramsey-Klawsnik, a social worker and family therapist, noted that one form of elder abuse often overlooked or ignored is sexual abuse, as there is a prevailing myth that elders and sex do not go together. She warned, however, “We’ve unfortunately had to get used to the idea that sometimes parents molest their children, and we also have to get used to the idea that sometimes adult children molest their elders. It is a difficult but necessary piece of information to swallow.” Elder sexual abuse occurs when a senior is forced, manipulated, or coerced into unwanted sexual activity, or when a senior lacks the capacity to grant informed consent to sexual activity. Ramsey-Klawsnik discussed a number of substantiated cases of sexual assault of elderly victims perpetrated by paid or volunteer caregivers, family members, or spouses. Her cases illustrated that although the majority of identified victims are female, disabled men also are vulnerable. Most identified perpetrators are male; however, some cases have involved female perpetrators. Several factors are correlated with the impact of sexual abuse on victims. These include the victim’s preabuse level of function, and the type of abuse sustained (“hands-off” offense such as sexual harassment, “hands-on” offense such as rape or molestation, or harmful genital practices such as a caregiver unnecessarily performing invasive cleansing procedures). Victim impact also is related to the extent of abuse suffered (one-time vs. recurrent episodes), and whether or not appropriate interventions are offered to assist the victim. Professional and community response to elder sexual abuse often is denial or minimization. It is an abhorrent issue to contemplate and discuss, and therefore it is easy to dismiss indicators and deny the existence of this type of victimization. Those involved with older persons need to realize that if signs and symptoms exist

in an older person that would suggest sexual assault in an 8-, 20-, or 40-year-old, the matter should be investigated.

8.4.8 INSTITUTIONAL ABUSE

AND

NEGLECT

In March 2002, the U.S. GAO delivered a report to the Senate Special Committee on Aging on the results of 18 months of interviews with relatives of residents in nursing homes around the country and with officials in Georgia, Illinois, and Pennsylvania. The GAO documented instances of alleged physical and sexual abuse that were frequently not reported or prosecuted. At risk for further abuse were the 1.5 million residents of 17,000 nursing homes in the United States. According to the GAO report, most of the local police departments in those three states reported that they were seldom summoned to a nursing home following an alleged instance of abuse; instead, state survey agencies were typically notified of allegations of abuse, but these notifications were frequently delayed. Allegations of abuse might not be reported immediately for a variety of reasons, including reluctance to report abuse on the part of residents, family members, nursing home employees, and administrators, according to GAO investigators. Victims of crimes ordinarily call the police to report instances of physical and sexual abuse, but when the victim is a nursing home resident, the police appear to be notified infrequently, according to the report. Residents and family members are not required to notify local police of abusive incidents. Several police officials told the GAO that when they do learn of an allegation of abuse involving a nursing home resident, it is sometimes after another entity, such as the state survey agency, has begun to investigate, thus hampering law enforcement’s evidence collection and limiting their investigations. Most of the police departments also indicated that they did not track reports of abuse allegations involving nursing home residents and thus did not have data on the number of such reports. When residents and family members do report allegations of abuse, they might complain directly to the nursing home administrator rather than contacting police. According to one long-term care ombudsman, residents and family members do not always view the abuse as a criminal matter. Nursing homes are usually not compelled to notify local law enforcement when they learn of such reports. There is no federal requirement that they contact police, although some states have instituted such a requirement. GAO investigators’ discussions with officials from 19 local law enforcement agencies indicated that police are rarely called to investigate allegations of the abuse of nursing home residents. The GAO’s review of 158 case files from 1999 and 2000 indicated state survey agencies were often not promptly notified of abuse allegations, with reports made sometimes days and weeks after the abuse occurred. Although individuals filing complaints are not compelled

Vulnerable Populations

to report allegations within a prescribed time frame, nursing homes in the states the GAO visited are required to notify the state survey agency of abuse allegations the day they learn of the allegation or the following day. Experts say that allegations of abuse of nursing home residents might not be reported promptly for a variety of reasons. For example, a recent study by Burgess and Dowdell (2000) found that nursing home staff might be skeptical that abuse occurred. Residents might also be afraid to report abuse because of fear of retribution. According to one law enforcement official interviewed by GAO investigators, family members are sometimes fearful that the resident will be asked to leave the home and are troubled by the prospect of finding a new place for the resident to live. Additionally, nursing home staff and management do not always report abuse promptly, despite requirements to do so. According to law enforcement and state survey agency officials, staff fear losing their jobs or facing recrimination from coworkers and nursing home management. Similarly, they also said that nursing home management is sometimes reluctant to risk adverse publicity or sanctions from the state. GAO investigators encountered a number of examples of delayed reporting by health care providers. A nursing home resident reported to a nurse that she had been raped. Although the nurse recorded this information in the resident’s medical record, she did not notify the facility’s management. She also allegedly discouraged the resident from telling anyone else. Two months later, the resident was admitted to a hospital for unrelated reasons and told hospital officials that she had been raped. It was not until hospital officials notified police of the resident’s complaint that an investigation was conducted. Investigators then discovered that the resident had also informed her daughter of the incident, but the daughter had dismissed it. The resident later told police that she did not report the incident to other nursing home staff because she did not want to cause trouble. The case was closed because the resident could not describe the alleged perpetrator. However, the nurse was counseled about the need to immediately report such incidents. In another instance, a nursing assistant angered by a resident who soiled his bed threw a pitcher of cold water on the patient and refused to clean him; another aide witnessed the incident. Instead of informing management, the witness confided in a third employee, who reported the incident to the nursing home administrator five days after the abuse took place. The abusive aide was fired, and a finding of abuse was recorded in her nurse aide registry file. In another case, one nursing home employee witnessed an aide slap a resident; two other employees heard the incident. The aide denied the allegation, yet the resident developed redness, swelling, and bruising around her eye. The witnesses reported the matter to nursing home management, which investigated the situation and

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suspended the aide the next day; the aide was subsequently fired. However, the state survey agency was not notified of the incident by the home until 11 days after the abuse took place. The GAO report identified the fact that relatively few prosecutions result from allegations of physical and sexual abuse of nursing home residents. Investigators identified two impediments to the successful prosecution of employees who abuse nursing home residents: Allegations of abuse were not always referred to local law enforcement, and a lack of witnesses to instances of abuse made prosecutions difficult and convictions unlikely. The lack of compelling evidence often precludes prosecution of those who have abused nursing home residents, the GAO report discovered, adding that according to law enforcement officials, nursing home residents are often unwilling or unable to provide testimony. GAO file reviews confirmed that residents were reluctant or unable to provide evidence against an accused abuser in 32 of the 158 cases the agency reviewed, thus making it difficult to pursue a criminal investigation. GAO investigators noted several instances in which residents sustained unexplained black eyes, lacerations, and fractures; however, despite the existence of serious injuries, investigators could neither rule out accidental injuries nor identify a perpetrator. Prosecutions of individuals accused of abusing nursing home residents are often weakened by the time lapse between the incident and the trial. Law enforcement officials and prosecutors told the GAO that the amount of time that elapses between an incident and a trial could ruin an otherwise successful case because witnesses do not always remember important details about the incident. The GAO’s review demonstrated that nursing home residents might become incapable of testifying months after they were abused. For example, in one case, a victim’s roommate witnessed the abuse and positively identified the abuser during the investigation. However, by the time of the trial, nearly five months later, she could no longer identify the suspect in the courtroom, prompting the judge to dismiss the charges. Moreover, given the age and medical condition of many nursing home residents, many might not survive long enough to participate in a trial. Burgess and Dowdell’s (2000) study of 20 sexually abused nursing home residents revealed that 11 died within one year of the abuse. The GAO report stated that law enforcement officials believe that without testimony from either a victim or a witness, conviction is unlikely. One of the safeguards against elder abuse should be the screening of health care providers. Requirements by the Centers for Medicare and Medicaid (CMS) preclude facilities from employing an individual convicted of abusing nursing home residents but permit the hiring of those convicted of other abusive acts, such as child abuse. Although some states have established more stringent requirements, criminal background checks typically do

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not identify individuals who have committed a crime in another state, according to the GAO report. Nursing homes can be cited for deficiencies if they fail to adequately protect residents from abuse, but these deficiencies rarely result in the imposition of sanctions, such as civil monetary penalties, by state survey agencies. State survey agencies, which also oversee the operation of state nurse aide registries, do not adequately ensure that residents will be protected from aides who previously abused residents. Finally, states are unable to take professional disciplinary actions against other employees, such as security guards or housekeeping staff, who might have abused residents but who are neither licensed nor certified to care for residents. Although CMS requires nursing homes to establish policies that prevent the hiring of individuals who have been convicted of abusing nursing home residents, this requirement does not include offenses committed against individuals outside the nursing home setting, nor does it specify that states conduct background checks on all prospective employees. CMS’s requirement does not preclude individuals with similar convictions, such as assault, battery, and child abuse, from obtaining nursing home employment. Nationwide background checks on prospective nursing home employees can be performed by the FBI if nursing homes request them. These checks could identify offenses committed elsewhere, but not all states take advantage of this option. According to the GAO report, 21 states have requirements that subject some health care employees to these checks, but state requirements vary and do not always apply to prospective nursing home employees. The GAO report revealed that many states do not levy sanctions against nursing homes for deficiencies associated with their handling of instances of abuse. According to the report, severe deficiencies, including those resulting in actual harm or immediate jeopardy to resident health or safety, could result in an immediate sanction such as a civil monetary penalty. Deficiencies not resulting in actual harm or immediate jeopardy usually resulted in nursing homes being required to submit a plan of corrective action. In the GAO’s review of 158 cases, 26 nursing homes were cited for abuse-related deficiencies such as failing to report allegations of abuse in a timely manner or failing to properly investigate them, as well as inadequately screening employees for criminal backgrounds. Bertsch (2003) suggests that nursing homes can fight against incidences of elder abuse by doing the following: • •

•

Hire licensed nurses who have geriatric experience. Ensure that allegations of abuse are reported immediately to the administrator responsible for reporting to officials in accordance with state law. Implement written policies and procedures that prohibit mistreatment, neglect, and abuse of res-

•

•

•

•

•

•

idents and misappropriation of resident property; include expected consequences for abusers and those who do not report abuse. Conduct criminal background checks on all nursing employees by referring to state boards of nursing, nurse aides’ registries, and police records. Before hiring applicants, check references from former employers and instructors even if they are permitted to supply dates of employment only; for certified nursing assistants, check state registries for current certification and status, and for licensed nurses, verify current licenses, and check with state licensing boards to ensure no penalties are pending. Provide regular educational programs on how to understand residents’ behavior and provide care, including simulation of residents’ physical impairments. Require written accident reports for all resident accidents; evaluate them quarterly, and track for ongoing trends. Initiate an open-door policy to encourage staff to freely discuss suspicions of abuse and share suggestions. Emphasize residents’ rights when hiring new nursing staff.

Bertsch (2003) also suggests that nurses who work in long-term care facilities do the following: • • • • •

•

Learn how to identify abuse and potential elder abuse. Monitor trends of potential and actual abuse. Physically assess all residents while making rounds. Observe staff members who provide direct patient care. Become familiar with your state’s advocacy system, including ombudsman, state licensing agency, and consumer advocacy groups. Facilitate staff participation in educational programs on abuse that emphasize the recognition of signs of elder abuse, its causes, and reporting protocols.

“Even in the most proactive nursing homes, daily demands on staff continue to put residents at risk for abuse,” Bertsch writes. “Residents’ inability to protect themselves accentuates the need for protective measures in both nursing homes and agencies that oversee them. But even efforts to screen employees and prompt reporting can fall short of creating a tight enough net to protect residents from potential offenders.”

Vulnerable Populations

Several recent initiatives have emerged to address abuse. CMS has created the Internet-based program Nursing Home Compare at www.medicare.gov/Nhcompare/home.asp. All nursing homes participating in Medicare and Medicaid are subject to review on nine quality measures, such as how often a facility uses physical restraints to manage residents, the percentage of residents with pressure sores and weight loss, and a list of deficiencies found by state licensing surveyors that details the scope and severity of each deficiency. The GAO report made the following recommendations to CMS: •

•

•

•

•

Ensure that state survey agencies immediately notify local law enforcement agencies or the Medicaid Fraud Control Unit (MFCU) when nursing homes report allegations of physical or sexual abuse of residents or when the survey agency has confirmed complaints of alleged abuse. Accelerate the agency’s educational campaign on reporting nursing home abuse by distributing its new poster with clearly displayed complaint telephone numbers and requiring state survey agencies to ensure that the numbers are prominently listed in local telephone directories. Systematically assess state policy and practices for complying with the federal requirement to prohibit employment of people convicted of abusing nursing home residents and, if necessary, develop more specific guidance to ensure compliance. Clarify the definition of abuse and otherwise ensure that states apply that definition consistently and appropriately. Shorten the state survey agencies’ time frame for determining whether to include findings of abuse in nurse aide registry files.

“Nurses who are aware of nursing home abuse can educate others about ways to prevent it,” Bertsch writes. “In particular, RNs who work in nursing homes know the importance of immediate notification of resident abuse to state survey agencies. Likewise, nurses in hospitals should be on the alert for signs of abuse when residents are admitted from nursing homes and must know how to notify authorities when necessary. Community health nurses should also be on the alert for signs of abuse when their patients are discharged from nursing homes to prior or new living arrangements.” Bertsch points to the current nursing shortage as an aggravating factor of elder abuse. “A serious shortage situation confronts the nursing profession, including an RN vacancy rate of 18 percent in nursing homes.” To address this challenge, Bertsch advocates incorporation of long-term care experience in nurs-

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ing school curricula, increased promotion of the ANA credentialing program in gerontology, and support for nurses who wish to study gerontology in graduate programs. “One day federal regulations may mandate nursing homes to staff with RNs skilled in geriatric nursing,” Bertsch writes. “As professional nurses move into geriatric settings as role models, their presence could have an impact on employee attitudes, work habits, and relationships with residents leading to the decline and perhaps eradication of nursing home abuse.” 8.4.8.1 The New Nursing Home Challenge: Resident-on-Resident Violence Gray-Vickery (2004) reports that between 1999 and 2001, 30 percent of nursing homes in the United States were cited for abuse. Abuse in institutions is often triggered by stressful working conditions, staff burnout, patient aggression, or negative attitudes toward the elderly. Abuse and neglect of elders at the hands of caretakers in nursing homes and other institutions has been well documented in the lay press, in the medical literature, and in countless books, but a new problem is developing that some experts say could be addressed by forensically trained health care providers. In 2004, an 88-year-old patient in a Stamford, Connecticut nursing home was bludgeoned to death by his 82year-old roommate, who used the footboard of a bed as the weapon. This case of an assailant who suffered from dementia is casting new light on the emerging problem of violence among facility residents. Even as policymakers, investigators, and advocates have focused on complaints of staff abuse, resident-on-resident violence is triggering an increasing number of complaints, studies, and conferences, according to an October 6, 2004 Associated Press story. The article reported, “Nationwide, more than 3,700 complaints about such abuse were lodged with state ombudsmen programs in 2002, up from about 2,500 in 1997.” Pennsylvania, New York, and Florida have reported cases in recent years of patients killed by fellow residents suffering from dementia. “There’s so many situations occurring now where there is resident-on-resident abuse, including cases where people are killed occasionally,” said Janet Wells, director of public policy for the National Citizens Coalition for Nursing Home Reform, who was quoted in the AP story. Patient advocates say more staff and better training, as well as improved screening of patients for mental illness or criminal backgrounds is needed to address the problem. In the AP story, Wells said that nursing homes are eager to fill beds and might not inquire as to a patient’s background. In Oklahoma, a group called A Perfect Cause warned that violent offenders were being warehoused in nursing homes. In 1999, an 83-yearold woman died after she was thrown against a wall by another resident who had an extensive criminal record. In

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2003, 16 residents were killed in a Hartford, Connecticut nursing home when the facility caught fire. The blaze was set by a 24-year-old resident who was known to be mentally ill. In another case, a 23-year-old mentally ill man slashed an elderly resident’s throat because he was upset that the man had taken a cookie from him. In the summer of 2004, Minnesota Attorney General Mike Hatch filed a lawsuit against a nursing home, alleging that it jeopardized the health and safety of vulnerable adults patients by accepting multiple convicted sex offenders to its facility, and by condoning the presence of other deplorable conditions. The lawsuit alleged that the 94-bed nursing home accepted referrals of convicted sex offenders from Minnesota prisons in 2002, 2003, and 2004. One of the sex offenders, a 44-year-old man, had been charged with first- and second-degree criminal sexual conduct against a vulnerable adult. Within days of arriving at the facility named in the lawsuit, the offender had developed a friendship with a female resident. After the patient learned of the man’s criminal history, she attempted to end the friendship. The man began to follow the female resident and one night was found in her room, hovering over her while she was in bed. He was discharged back to the Minnesota Correctional Facility a month after arriving at the nursing home. The facility had also admitted a 26year-old male sex offender, JA, who had a history of pedophilia. Around the same time, a 43-year-old female, NM, with diagnoses including mental retardation, borderline intelligence, and schizophrenia, had been admitted. Less than 10 days after NM’s admission to the facility, JA was found in NM’s room, fondling her “private parts.” A few days later, NM was taken to the ER for abdominal bleeding. JA admitted penetrating NM’s vagina. Witnesses also observed JA grabbing NM’s buttocks. A picture of NM naked from the waist down, lying on her back with her legs spread apart, was found in JA’s wallet. The facility had instructed an employee of the facility to destroy this piece of evidence, but he refused to do so. Allegedly, the facility management thought that the relationship between JA and NM was “cute” and talked about buying a ring for JA to present to NM. Hatch’s lawsuit alleges that the facility failed to inform its staff, residents, their families and others that convicted sex offenders were residing there, among other charges of unsafe, inappropriate, and deplorable conditions. Noted forensic pathologist Vincent DiMaio, MD, says forensic nurses are needed in nursing homes to help identify and document forensic cases, both obvious and subtle. “While I see forensic nurses excelling in working as investigators for medical examiners, I see them in an equally important role,” DiMaio says: One of the major problems we are having in society now is care of the elderly. The nursing homes are horror stories in many areas, and in my office we get 2,000 deaths a

Forensic Nursing

year reported to us in nursing homes . . . we can’t investigate them all. How can I send my investigator, a certified, commissioned peace officer to review the medical records of someone in a nursing home? They don’t understand what they are reading. You can tell them what happened, but they won’t be able to pick up on the medical and clinical nuances like forensic nurses can. The U.S. population is getting older and attention is being drawn to the problem of abuse and neglect in nursing homes. There is some talk of making a law that says the family of a victim is entitled to an autopsy of anyone who dies in a nursing home so that the circumstances can be investigated . . . the problem is, some medical examiners are fighting it. I would like it, but it’s hard for me to handle all of these nursing home cases already. That’s why we need nurse investigators. I testified in a case in Honolulu which centered on a nursing home in which one of the residents died of decubitus ulcers. The facility operator was charged with murder, was convicted, and got 20 years. In that case, it was all done retrospectively; think about how easy it would be for me to investigate these cases if I had nurse investigators who are familiar with natural disease as well as suspicious injury and death.

8.4.8.2 Underreporting of Elder Abuse Although all states have laws and services in place to detect elder abuse, a 1996 study indicated that only about one in five cases of elder abuse is reported and substantiated. This low level of intervention, despite laws and services, prompted University of Iowa Health Care researchers to pursue their own study. The findings, which appeared in the December 2004 issue of the American Journal of Public Health, indicate that how domestic elder abuse cases are detected and handled differs significantly across states because the relevant state laws and regulations vary greatly. In particular, the study found that states that require mandatory reporting and tracking of domestic elder abuse reports have much higher investigation rates than states without these mandatory requirements. The study is believed to be the first to comprehensively relate domestic elder abuse rates to laws and regulations in all 50 states and the District of Columbia. The University of Iowa study suggests that particular professions need not be singled out in statutes as mandatory reporters, and that types of abuse need to be better defined within many state regulations. In addition, the findings indicate that it might be more effective to have caseworkers handle only adult abuse cases rather than both child and adult cases. “Laws do have an impact on public health, and this study demonstrates that different aspects of laws related to domestic elder abuse impact the amount of abuse reported, investigated and found to be actual abuse,” says Gerald Jogerst, MD, associate professor and interim head of family medicine in the University of Iowa Roy J. and Lucille A. Carver College of Medicine and lead investigator of the

Vulnerable Populations

study. “Our findings suggest that improvements and standardization are needed nationwide in how information on elder abuse is collected and how state laws are created.” The University of Iowa study was based on data for 1999 that included all available domestic elder abuse reports, investigations, and substantiations. Specifically, there were 190,005 reports from 17 states (not all states keep track of reports); 242,530 investigations from 46 states and the District of Columbia; and 102,879 substantiations from 35 states. A total of four states were not included in the investigation totals because they either reported no data (Georgia, North Dakota, Ohio) or were not sure of its accuracy (Colorado). In addition, not all states were able to provide substantiation of investigation data. A report is an allegation or suspicion of abuse received by a state’s APS; an investigation involves actually going to a potential victim’s home to see whether abuse is taking place; and substantiation is the finding of abuse as defined by that state’s law. The University of Iowa team analyzed each state’s statute and regulation regarding APS. The team of researchers found that domestic elder abuse reports ranged from 4.5 per 1,000 elders in New Hampshire to 14.6 in California. “The range of reporting rates is very high, and is one of the indicators that there is high variability in how states document elder abuse,” Jogerst says. Elder abuse investigations rates ranged from .5 per 1,000 elders in Wyoming to 12.1 in Texas. Substantiations ranged from .1 per 1,000 elders in Wyoming to 8.6 in Minnesota. Forty-five percent of cases investigated were substantiated as actual abuse according to state laws. The terminology used to describe elder abuse varies greatly. As a result, the University of Iowa team first had to review and recodify terms used so that appropriate comparisons could be made across states, says Jeanette Daly, PhD, a University of Iowa geriatric nurse researcher in family medicine and the study’s coprincipal investigator. “The team members drew on the disciplines of nursing, medicine, law, biostatistics and social work. We worked together to code more than 80 aspects of the different statutes and come to consensus about categorizing these definitions,” Daly adds. In addition, variations are widespread in how states document cases. For example, some states, including Iowa, used the term report in summaries when referring to what, by standard definition, is considered an investigation. “The National Association of Adult Protective Services has a model reporting system for states to mimic. However, some states are hindered in implementing the model because their adult and child protection services share a computerized system,” Daly says. The team found that mandatory reporting, which was part of the law in 44 states during the year studied, is linked to higher investigation rates. Although mandatory reporting apparently affects how many elder abuse cases are investigated, the researchers found that it is not necessary for states to spend time and resources defining who

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should be a mandatory reporter. “Some states list ‘any person’ as a mandatory reporter and other states list professionals such as physicians, nurses and bankers,” Jogerst says. “However, when you compare these two groups of states, there is no overall difference in the number of reports, investigations or substantiations. The law simply should say ‘any person.’” States that tracked reports had more investigations and nearly three times as many substantiated cases as did states that did not track reports. This was true even when considering how much funding a state has to track such cases. “We think an aspect of this requirement to track reports puts administrators and workers on alert that they are being monitored in their performance,” Jogerst says. “It also sends a message that the state government feels that tracking reports is important.” The team also found that states where investigators handle only elder abuse cases had a nearly 50 percent substantiation ratio compared to a 34 percent substantiation ratio in states where investigators handle both child and elder abuse cases. The substantiation ratio was determined by dividing the number of substantiations by the number of investigations. “This substantiation difference may exist because investigators devoted to one type of abuse probably acquire more expertise by doing more elder abuse investigations,” Jogerst says. Iowa is one of 11 states that currently have protective services caseworkers handling both elder and child abuse cases. The team also determined that it is “worth the time to spell out abuse definitions within regulations.” Abuse definitions are broken down into eight categories: abandonment, emotional or psychological, exploitation (usually financial), sexual, self-neglect, neglect (by another person), physical, and abuse not otherwise specified. Selfneglect is the failure, either by the adult’s action or inaction, to provide the proper or necessary support or medical or any other care necessary for his or her own well-being. “We saw that state regulations that included most or all of the abuse definitions have increased substantiation rates and ratios,” Jogerst says. “This suggests investigators can do a better job of documenting abuse when they have more to go on and the definitions are clear and precise.”

8.4.9 THE PUBLIC HEALTH RESPONSE ABUSE . . . OR LACK THEREOF

TO

ELDER

With elder abuse coming to light in the United States in the 1970s through congressional hearings, scientific research, and exposure in the media, came enactment of state adult protective service and elder abuse reporting laws to identify and treat elder abuse. The majority of the laws were passed during the early 1980s, and today all states have some kind of law for victims of elder abuse, although they differ widely in content. In the early 1990s, Ehrlich (1991) reported that state laws include mandatory reporting, a provision regarded by some as important for

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case finding. Ehrlich writes, “The usefulness of mandatory reporting rests in the ability of those identified as reporters to recognize elder abuse and make effective referrals for service. Elder abuse protocols help facilitate this.” Health care providers are major referral sources for elder abuse, and also are most commonly identified as mandatory reporters in elder abuse reporting laws (Fulmer & O’Malley, 1987). Ehrlich (1991) says, “Conventional wisdom suggests that public-health officials are the most informed health care providers about laws affecting the safety and welfare of vulnerable populations. It is reasonable to think, therefore, that they are knowledgeable about state elder abuse reporting laws and procedures for their appropriate implementation.” To test this assumption, a survey (consisting of a two-page questionnaire) was conducted of the 50 state health department officials between April 1989 and October 1989. A cover letter accompanying the survey also identified these staff members as “front-line workers who can make a significant contribution to the early identification of abuse situations.” Abuse was defined to include physical abuse, neglect, exploitation, and abandonment. Two follow-up mailings to nonrespondents plus five telephone interviews resulted in a response rate of 100 percent. The Survey of State Health Departments on Elder Abuse Reporting Procedures uncovered the following: •

•

•

•

Thirty-eight departments reported that they had no protocol specifically prepared for staff members or related community professionals. More than half (18) of them indicated that it was not the responsibility of their department. One respondent wrote, “Protocols are not necessary, the law is clear.” Ten health departments reported that they had protocols. A re